2. Case or Incident # (if known):
3. Date:
   Date:
5. Your Name:

   Last, First, Middle

7. Cell Number:
8. Home Number:
10. E-mail:
12. Address:

    Street, City/Town, State, Zip Code

14. Complainant:

    Last, First, Middle

16. Preferred Method of Contact:
18. Incident occurred on:

    Date, Time, Location

22. Employee(s)/Officer(s) involved:
24. Name:
25. ID#:
27. 1.
28. 1.
30. 2.
31. 2.
33. 3.
34. 3.
36. 4.
37. 4.
39. Witness(es) to Incident:
41. Name:
42. Address:
43. Phone Number:
45. 1.
47. 2.
49. 3.
51. 4.
53. Best Way to Locate Witness(es):
57. APPENDIX A - LAW ENFORCEMENT OFFICERS' BILL OF RIGHTS - PG1500.0
59. Please provide us with detailed information regarding this matter in your own words: (use extra paper if necessary and attach to this form.)
61. Complaining Party Signature*
62. Date
    Date
66. THIS SECTION ONLY APPLIES TO COMPLAINTS OF POLICE BRUTALITY
68. Please fill out to the best of your ability below.

    Ex. I hereby certify that on this ______ day of ______, ______, before me, a DISTRICT COMMISSIONARY/NOTARY PUBLIC of said state and county aforesaid, personally appeared ________ and made oath in due form of law that the matters and facts as related above are true.

70. STATE OF MARYLAND COUNTY OF:
72. I hereby certify that on this
73. day of
75. , before me, a DISTRICT COMMISIONARY/NOTARY PUBLIC of said state and county aforesaid, personally appeared
77. and made oath in due form of law that the matters and facts as related above are true.
79. My commission expires:
80. District Commissioner/Notary Public Signature
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

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