2. Person Making Report (Optional, but Helpful)
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. Email
14. DOB
18. Officer(s) Subject to Allegation - Provide Whatever information is Known
20. Officer(s)
21. Badge #
23. Incident Site
24. Date / Time
    Date / Time

    Date / Time
26. 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.
30. Other Information
32. How was this reported
    -- Select One --In PersonPhoneLetterEmailOther
34. If Other:
36. Any physical evidence submitted?
    -- Select One --YesNo
38. If yes, describe
40. Was incident previously reported?
    -- Select One --YesNo
42. If yes, describe
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field