Formal Complaint Form

Formal Complaint Form
Complainant Name:*
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:*
Please enter a valid phone number.
Alternative Phone:*
Please enter a valid phone number.
Email:
A copy of the report will be emailed if filled in.
Complaint Made Against:

Complete at least one of Officer Name, Officer Number, or Car Number.
Officer Name:*
Officer Number: (Badge Number)*
Car Number:*
Summary of Complaint:*
Location of Occurence:*
Date and Time of Occurence:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Was there another known witness:

YesNo
Witness Information
Name:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone:*
Please enter a valid phone number.
Alternative Phone:*
Please enter a valid phone number.
By signing this document, I, {complainantName}, the complainant or witness to the offense as related above do swear, or affirm, under penalty for perjury, as specified by IC 35-44-2-1, that the foregoing representations are true. Any false statement you make and that you do not believe to be true may subject you to criminal prosecution as a Class B Misdemeanor.
Complainant Signature:*

Clear
Date of Signature

MonthDayYear
Date
Time of Signature

Hour Minutes

AM/PM Option
Current Date

MonthDayYear
Date
Current Time

Hour Minutes

AM/PM Option
Reviewed By:
Date of Review

MonthDayYear
Date
Time of Review

Hour Minutes

AM/PM Option
Should be Empty:

Complaint Made Against: