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2. Complainant Information
   This form is to be completed by the person making the complaint.
4. Whole Name
5. Date of Birth
   Date of Birth
7. Home Phone
8. Work Phone
9. Other Contact Number
11. Address
13. City
14. State
15. Zip Code
19. Officer(s) Involved (if known)
21. Officer Name
22. Badge Number
23. Car Number
25. Officer Name
26. Badge Number
27. Car Number
29. Officer Name
30. Badge Number
31. Car Number
33. Officer Name
34. Badge Number
35. Car Number
37. Officer Name
38. Badge Number
39. Car Number
41. Officer Name
42. Badge Number
43. Car Number
47. Witness Information
49. Name
50. Phone
52. Address
54. City
55. State
56. Zip Code
60. Name
61. Phone
63. Address
65. City
66. State
67. Zip Code
71. Name
72. Phone
74. Address
76. City
77. State
78. Zip Code
82. Name
83. Phone
85. Address
87. City
88. State
89. Zip Code
93. Name
94. Phone
96. Address
98. City
99. State
100. Zip Code
104. Incident Details
106. Date & Time of Incident
     Date & Time of Incident

     Date & Time of Incident
107. Incident Number (if known)
109. Location of Incident
111. City
112. State
113. Zip Code
115. Nature of Complaint
117. I,
118. Name of Complainant
119. , hereby accuse
121. Name(s) of Officer(s)

122. if known, a member or employee of the Prescott Valley Police Department,

124. of misconduct and/or improper procedure, the facts of which are set forth above. I formally request that the incident be investigated in accordance with the Prescott Valley Policies and Procedures. I understand that I may be required to give additional statements to investigators, attend public hearings of this matter and that my failure to do so will result in dismissal of this complaint. I understand that I may be asked to submit to a polygraph exam as a part of this investigation when necessary. I declare that the above statement is true and correct. I understand that giving a false statement, which is intended to mislead a public servant in the performance of his/her official function, is punishable under Arizona Law, ARS 13-2907.01.

126. Signature of Person Making Complaint
127. Date
     Date
Leave This Blank:


129. 1. Receive an email copy of this form.
130. Email address

     This field is not part of the form submission.

131. Submit

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