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.Format: (000) 000-0000.
Alternative Phone:
Please enter a valid phone number.Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Was there another known witness:
Witness Information
Name:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone:
Please enter a valid phone number.Format: (000) 000-0000.
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:
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Signature

Hour Minutes

AM/PM Option
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Time

Hour Minutes

AM/PM Option
Reviewed By:
Date of Review

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Review

Hour Minutes

AM/PM Option
Should be Empty:

Formal Complaint Form

Complaint Made Against:

Witness Information