Citizen Complaint Form

2. YOUR INFORMATION
   Please provide your contact information.

   Please provide your contact information.

4. Name*

5. D.O.B.

7. Address*

9. Best Phone Number to Call

10. Best Time to Call

11. Email Address

13. WITNESS INFORMATION
    Please provide contact information for any witnesses.

    Please provide contact information for any witnesses.

15. Name

16. Address

17. Phone Number

19. Name

20. Address

21. Phone Number

23. Name

24. Address

25. Phone Number

27. OFFICER / EMPLOYEE INFORMATION
    Please provide the names of the officer(s) or employee(s) involved.

    Please provide the names of the officer(s) or employee(s) involved.

29. Name

30. Name

32. Name

33. Name

35. If you do not know the names of the employees or officers, please provide comments here:

37. INCIDENT DETAILS
    Please provide information regarding the incident.

    Please provide information regarding the incident.

39. Date of Incident

40. Time of Incident

41. Case Number (if known)

43. Location of Incident (address or description)

45. Narrative (please provide a detailed summary of your complaint)

47. What is your desired outcome?

49. SIGNATURE AND ACKNOWLEDGEMENT
    By signing this form, I acknowledge that the information I’ve provided is true and correct to the best of my knowledge. I understand that it is a criminal offense to make a false statement to a member of the police department, pursuant section 76-8-503 and/or 76-8-504, of the Utah Criminal Code. I understand that digital signatures are considered legal in the State of Utah.

    By signing this form, I acknowledge that the information I’ve provided is true and correct to the best of my knowledge. I understand that it is a criminal offense to make a false statement to a member of the police department, pursuant section 76-8-503 and/or 76-8-504, of the Utah Criminal Code. I understand that digital signatures are considered legal in the State of Utah.

51. Signature /S/

Leave This Blank:


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

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field