Name: Home Address: City: State: Zip Code: Phone #: DOB: SSN/OL: Age: Sex: Race: Employer/School: Phone #: Employer/School Address: City: State: Zip Code: Phone #: INCIDENT Nature of Complaint: Officer: Officer: Incident Date: Incident Time: Date/Time Reported: How Reported: Incident Location: Description of Incident: Signature of Complainant: Date: DEPARTMENT USE ONLY Action Taken: Chief Signature: Date: Leave this field blank
