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2. Person Making Report (optional, but helpful)
4. Full Name
5. Phone Number
7. Address (Apt #)
8. Email
10. City / State / Zip
11. Date of Birth
15. Officer(s) Subject to Allegation (provide whatever info is known)
17. Officer(s) Name
18. Badge Number(s)
20. Incident Location
21. Date/Time

23. In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct.  If you do not know the officer's name or badge number, provide any other identifying information.

25. Description of Incident
27. Do you have any physical evidence to submit? (Answer Yes or No and describe evidence)
28. Was incident previously reported? (Answer Yes / No and explain)
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field