Complaint Intake Form

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

    This field is not part of the form submission.

55. Submit

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