Citizen Complaint Against Officer

Officer Involved:

Report Number:

Date of Incident:

Time of Incident:

Location of Incident:

City ST ZIP:

Complainant:

Telephone:

Your Address:

City ST ZIP:

Driver’s License Number:

DOB:

Relationship to Officer Involved?

Witnesses:

Name

Address

Phone

Any Prior Contacts with Officer Involved?

yesno

Have you ever made a complaint against a police officer before?

yesno

If yes, what was the complaint?

What department was involved?

Officer involved?

Statement of Complainant:

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 $1000 fine.