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2. Citizen Complaint Against Officer
4. Officer Involved
5. Report Number
7. Date of Incident
   Date of Incident
8. Time of Incident
   Time of Incident
10. Location of Incident

    Address Example: 0000 Street Name

11. City, State, Zip Code
13. Complaintant Name
14. Phone
16. Relationship to Officer Involved
18. Your Address
19. Adress Line 2
21. City
22. State
23. Zip Code
25. Witnesses
27. Name
28. Address
29. Phone
31. Name
32. Address
33. Phone
35. Name
36. Address
37. Phone
39. Name
40. Address
41. Phone
43. Any prior contacts with officer involved?

    1. Yes
    2. No
45. Have you ever made a complaint against a police officer before?

    1. Yes
    2. No
47. If yes, what was the complaint?
49. What department was involved?
50. Officer involved?
52. Complaint

    Statement: A person making a false statement in their complaint shall be guilty of 2921.12 Falsification of the Ohio Revised Code. This offense is a Misdemeanor of the first degree which each violation can be punishable by up to 180 days in jail and/or a $1,000 fine.

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54. 1. Receive an email copy of this form.
55. Email address

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56. Submit Submit and Print

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