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2. First Name*
3. Last Name*
5. Phone Number*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Involved Officer(s)
16. Name
17. Car Number
19. Name
20. Car Number
22. Name
23. Car Number
25. Name
26. Car Number
28. Description of officer(s) if name(s) is/are unknown
30. Location of Occurrence*
31. Date of Occurrence*
32. Time of Occurrence*
34. Description of Occurrence*
36. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 2) you may still be required to provide a traditional signature at a later date.

    1. I agree.
38. Electronic Signature*
39. Date*
    Date
41. Witness Signature
42. Date
    Date

44. NOTE: Any person who knowingly files a false, misleading, or malicious allegation of misconduct on the part of a law enforcement officer shall be deemed guilty of a misdemeanor and upon conviction shall be fined not more than thirty (30) days. In addition, a civil suit by the officer complained against will be encouraged

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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

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