Citizen Comment Page
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Name of Complainant/Citizen:
Date: (mm/dd/yy)
Address: (street,city,state)
Home Phone:
Work Phone:
Email Address:
Date/Time of Incident/Occurrence:
Location of Incident/Occurrence:
Name(s) of Employee(s) Involved:

Statement:

Statement Continued (if needed):

I solemnly swear or affirm this statement to be the truth and I declare this to be a true and correct report and the information therein to be a fact.

Citizen's Name/Signature:


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