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2. Commendation or Complaint Intake*

   1. Commendation
   2. Complaint
4. Your Information
6. Last Name
7. First Name
8. Middle Initial
10. Phone Number
11. Email Address
13. Street Address
14. Apt
16. City
17. State
18. Zip

20. You may remain anonymous if you wish.

22. Incident Information
24. Date and Time
    Date and Time

    Date and Time
25. Case number
27. Address1
29. Address2
31. City
32. State
33. Zip
35. Officer or Employee Name
36. Badge Number
38. Were there any witnesses to this incident?

     If so, please provide the following:

40. First Name
41. Last Name
43. Phone Number
44. Address
46. First Name
47. Last Name
49. Phone Number
50. Address
52. Give us some details about the complaint or commendation.

     

54. Please Note:

    Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of their official duty shall be guilty of a misdemeanor of the second degree as provided in F. S. 837.06, 775.082-083-084.

56. Complainant Signature
57. Date
    Date
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

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