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2. Complainant Information:
4. Name:
6. Home Address:
8. Email Address:
9. Home Phone:
10. Cell Phone:
12. Complaint:
14. Case Number (if known):
15. Date of Incident:
    Date of Incident:
16. Location of Incident:
18. Complaint involves an Allegation of:
    -- Select One --Courtesy/RudenessNeglected DutiesUnprofessionalDriving RelatedExcessive ForceOther (Explain in Nature of Complaint)
19. Time of Incident
    Time of Incident
21. Nature of Complaint: (e.g. courtesy/rudeness. etc...)
23. Witness Information:
25. Witness Name: (1)
26. Witness Home Phone:
28. Witness Address:
29. Witness Cell Phone:
31. Witness Name: (2)
32. Witness Home Phone:
34. Witness Address:
35. Witness Cell Phone:
37. Member Information:
39. Member Name: (1)
40. Badge Number:
42. Was the Member in Uniform at the time of the incident?

    1. Yes
    2. No
43. Was the Member in a marked or unmarked car:

    1. Marked
    2. Unmarked
45. Member Name: (2)
46. Badge Number:
48. Was the Member in Uniform at the time of the incident?

    1. Yes
    2. No
49. Was the Member in a marked or unmarked car:

    1. Marked
    2. Unmarked
51. F.S.S. 837.06 Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provide in §775.082 or §775.083
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53. 1. Receive an email copy of this form.
54. Email address

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55. Submit

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