Name: First ________________________ Last __________________________
Address: ________________________________________________________
City _________________________ State _________ Zip ___________
Phone: Home ( ) __________________ Work ( ) ___________________
Cell ( ) ___________________ Emergency No. ( ) ____________
Email Address: ___________________________________________________
Employer: _______________________________________________________
Date of Birth: ____ /____ / _____ Current Age: _____________
Gender: ____ Male ____Female
Race: ____ African American ___ Asian ___ Hispanic ___ White ___ Other
INCIDENT INFORMATION
Incident Date: ____ / ____ / ____ Incident Time: ___:___ ___ a.m. or ___ p.m.
Incident Location: _________________________________________________
_________________________________________________________________
Name /Badge Number of Officer(s) Involved:
Officer ______________________________ Badge No. ____________________
Officer ______________________________ Badge No. ____________________
Officer ______________________________ Badge No. ____________________
Officer(s) Employed by: ____ Atlanta Police Department, OR
____ Atlanta Department of Corrections
Name(s) of Witness(es) to Incident:
Name ______________________________ Contact No. ___________________
Name______________________________ Contact No. ___________________
Name ______________________________ Contact No. ___________________
Is there any evidence available about the incident, such as copies of traffic tickets, police reports, photographs or medical records? ____ Yes or ____ No
If “Yes,” please describe and attach copies: ______________________________
_________________________________________________________________
_________________________________________________________________
Please describe your complaint (You may use additional paper if necessary):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Would you be willing to meet with the officer to discuss this issue? ____ Yes or ____ No
How did you hear about the ACRB? ____________________________________
_________________________________________________________________
I solemnly swear or affirm that the above statement is accurate.
Signature of Complaining Party:
Name: __________________________________ Date: _______________
Important Note! This complaint cannot be processed without a signature.