Jonesboro Police Department

Citizen Complaint Form

Date:
Internal Affairs Case #:
Complainant’s Name:
Complainant’s Address:
City:	State:	Zip:
Home Ph#	Work Ph#	Cell #
Type of Allegation:
Location of Occurrence:
Date of Occurrence:	Time:	am pm
Employee(s) Allegedly Involved:
Witness:
Name:	Address:	Phone:
Name:	Address:	Phone
Name:	Address:	Phone:

Description of Allegation/Statement of Complaint

Citizen Complaint Form

(Continued)

(If more space is needed, use back of form or attach a supplement)

COMPLAINT AFFIRMATION

I,	do hereby affirm that the foregoing information is true
and complete to the best of my knowledge and belief. I understand that any false, misleading, or
untrue statements or writing to any person(s) investigating this complaint, may subject me to
civil prosecution by the accused.
I further realize that it may become necessary, during the investigation of this complaint, for me
to meet with a member(s) of the Jonesboro Police Department to discuss this complaint; either in
the presence or absence of the accused department member(s) at the discretion of the department.
I hereby accept the premise that if any action is initiated through a court or administrative
hearing as a result of my complaint, my testimony before these hearing may be required. I
hereby agree to make myself available to aforementioned court or administrative hearing when
requested to do so.

Complainant’s Signature:

Related Incident Report Case # (attach copy)
Receiving Officer’s Signature:
Reviewed by:	Rank:

1

Turn in to Administration

IA Citizen Complaint Form_JPD206 F:\Police\Police Microsoft Doc Templates\Administration Form

Jonesboro Police Department

almerritt

2009-12-17

amrogers

City of Jonesboro