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2. Person Making Report (Optional, But Helpful)
4. Full Name
5. Phone Number
7. Address
8. Email Address
10. City
11. State
12. Zip Code
16. Officer(s) Subject to Allegation
18. Officer(s) Name:*
19. Badge Number:
21. Incident Location:*
22. Date / Time:*
    Date / Time:

    Date / Time:
24. In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct. If you cannot fit your response below, feel free to use extra pages and attach them to this document. If you do not know the officer's name or badge number provide any other identifying information. *
28. OTHER INFORMATION
30. How was this reported? *

    1. In Person
    2. By Phone

    1. By Letter

    1. By Email

    1. OTHER
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field