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2. Reporting Person
4. Last Name*
5. First Name*
6. Middle Name
7. Phone Number*
9. Residence Address*
10. City*
11. State*
12. Zip Code*
14. Business Address
15. Date of Birth
17. Persons Involved (if other than above)
19. Last Name
20. First Name
21. Middle Name
22. Date of Birth
24. Residence Address
26. Business Address
28. Day of Incident
29. Date of Incident
31. Location of Incident*
32. Time of Incident
34. Witnesses
36. Name
37. Address
38. Phone
40. Name
41. Address
42. Phone
44. If witnesses are not known, give their description.
46. Name or Description of Employee(s) Involved
48. Name
49. Badge or ID Number
50. Physical Description
52. Name
53. Badge or ID Number
54. Physical Description
56. Name
57. Badge or ID Number
58. Physical Description
60. Persons Arrested
62. Name
63. Address
64. Phone Number
66. Name
67. Address
68. Phone Number
70. Briefly describe details of complaint:
72. Racial or Identity Profiling PC 13519.4(e)
74. Do you believe you were stopped, arrested, searched, or detained by law enforcement based, at least in part, on your race or ethnicity (including color), nationality/national origin, gender, age, religion, gender expression, sexual orientation, mental disability, or physical disability?
    -- Select One --YesNo
76. Please explain or describe in detail why you believe you were stopped, arrested, searched, or detained based on your race or ethnicity (including color), nationality/national origin, gender, age, religion, gender expression, sexual orientation, mental disability, or physical disability:*
78. If you are alleging racial or identity profiling, please select from the following:
    -- Select One --Race or EthnicityNationalityGenderAgeReligionSexual OrientationMental DisabilityPhysical DisabilityGender Identity or Expression
80. Penal Code Section 832.5 Civilian Complaints Against Department Personnel
    You have the right to make a complaint against a police officer for any improper police conduct. California Law requires this agency to have a procedure to investigate civilian's complaints. You have the right to a written description of this procedure. This agency may find after investigation that there is not enough evidence to warrant action on your complaint. Even if that is the case, you have the right to make the complaint and have it investigated if you believe an officer behaved improperly. Civilian complaints and any reports or findings relating to complaints must be retained by the agency for at least five years.
82. I have read and understand the above statement.*

    1. I Acknowledge
84. A word of caution is offered concerning persons knowingly making false complaints about peace officers. Civil Code 47.5 (View note below) allows peace officers to bring civil action against a person filing a false complaint.
    Note: Section 47.5 Civil Code can be found on the California Law Website Section 47.5 Civil Code (Peace Officers; defamation action against person filing false complaint alleging misconduct, criminal conduct, or incompetence)... a peace officer may bring an action for defamation against an individual who has filed a complaint with that officer's employing agency alleging misconduct, criminal conduct, or incompetence, if that complaint is false, the complaint was made with knowledge that it was false and that it was made with spite, hatred, or ill will.
86. I have read and understand the above statement.*

    1. I Acknowledge
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88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit Submit and Print

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