Citizen Complaint Form - Village Of Butler Police Department

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VILLAGE OF BUTLER POLICE DEPARTMENT
Citizen Complaint Form
Date ___________________
Report #_________________
First Name__________________________ MI___________ Last Name_______________________________
Current Address ____________________________________________________________Apt_____________
City ___________________________________ Zip ____________________ Date of Birth _______________
Home Phone (_____)____________________ Cell Phone (_____)________________________
Employer__________________________________________________________________________________
Business Phone:________________________________ Work Hours:_________________________________
Incident Date and Time_______________________________________________________________________
Incident Location ___________________________________________________________________________
Name, Badge Number, and Rank of Accused officer(s), if known and incident description:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Witnesses to Incident:
First Name_________________________MI________Last Name____________________________________
Address___________________________________________________________________________________
Home Number_____________________________Cell Number______________________________________
Do you have an opinion as to how this situation should be resolved?
__________________________________________________________________________________________
__________________________________________________________________________________________
ACKNOWLEDGEMENT: I acknowledge that I have read the information on the reverse side of this form and
that the information and statement that I have provided in regards to my citizen complaint is true and accurate.
_______________________________ ________ ______________________________________ ________
Complainant Signature
Date
Witness Signature
Date
Rev 02/12

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