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Complaint Intake Form
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Complainant Information:
Name:
Home Address:
Email Address:
Home Phone:
Cell Phone:
Complaint:
Case Number (if known):
Date of Incident:
Date of Incident:
Location of Incident:
Complaint involves an Allegation of:
-- Select One --
Courtesy/Rudeness
Neglected Duties
Unprofessional
Driving Related
Excessive Force
Other(Explain in Nature of Complaint)
Time of Incident
Time of Incident
Nature of Complaint: (e.g. courtesy/rudeness. etc...)
Witness Information:
Witness Name: (1)
Witness Home Phone:
Witness Address:
Witness Cell Phone:
Witness Name: (2)
Witness Home Phone:
Witness Address:
Witness Cell Phone:
Member Information:
Member Name: (1)
Badge Number:
Was the Member in Uniform at the time of the incident?
Yes
No
Was the Member in a marked or unmarked car:
Marked
Unmarked
Member Name: (2)
Badge Number:
Was the Member in Uniform at the time of the incident?
Yes
No
Was the Member in a marked or unmarked car:
Marked
Unmarked
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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