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Citizen Complaint Statement

2. Use this form to submit a complaint regarding a member of the Police Department. DO NOT REPORT CRIMES HERE. PLEASE CALL 311 FOR NON-EMERGENCIES OR 911 FOR EMERGENCIES.

   Use this form to submit a complaint regarding a member of the Police Department. DO NOT REPORT CRIMES HERE. PLEASE CALL 311 FOR NON-EMERGENCIES OR 911 FOR EMERGENCIES.

4. Complainant*

6. Address*

8. Phone Number*

10. Date & Time of Incident*
    Date & Time of Incident

    Date & Time of Incident

12. Date & Time of Statement*
    Date & Time of Statement

    Date & Time of Statement

14. Police Personnel Involved*

16. Details of Incident & Specific Nature of Complaint*

18. Revised Code of Washington 9A.76.175 Acknowledgement*

    Making a false or misleading statement to a public servant. A person who knowingly makes a false or misleading material statement to a public servant is guilty of a gross misdemeanor. "Material statement" means a written or oral statement reasonably likely to be relied upon by a public servant in the discharge of his or her official powers or duties. Additionally, Officers who are the subject of malicious statements may have other legal recourse against a false accuser. I have read and understand the above statement.

    1. Yes
    2. No
20. Declaration*

    I declare and certify under penalty of perjury under the laws of the State of Washington that the preceding statement is true and correct.

    1. Yes
    2. No
22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature*

26. Received By:

28. Date & Time Received
    Date & Time Received

    Date & Time Received

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field