Citizen Concern

Name of Complainant

Address

Best Contact Number

Incident Date and Time

Name or Description of Employee Involved

Name(s) of Witness(es)

Witness(es) Contact Number(s)

Department Vehicle Involved (if applicable)

Location of Incident

Today's Date (mm/dd/yyyy)

Supporting Documentation

Nature or Description of Complaint

Brief Explanation

Specify any previous actions you have taken to resolve your complaint.

Specify remedy requested by you.

I hereby certify that the information stated above is true, correct, and complete to the best of my knowledge

Receive an email copy of this form. (Email)

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