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2. Contact Information:
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Home Phone Number*
16. Cell Phone Number
18. Business Phone Number
19. Email Address
21. Complaint Information:
23. Officer's Name and/or Badge Number*
25. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
26. Report Number (if known)
28. Were there any witnesses to this incident?

    1. Yes
    2. No
30. First Name
31. Last Name
33. Phone Number
34. Any more witnesses?

    1. Yes
    2. No
36. First Name
37. Last Name
39. Phone Number
41. Please Describe What Happened*
43. Electronic Signature
    Under penalties as provided by law for false certification pursuant to 735 ILCS 5/1-109 of the Code of Civil Procedure and Perjury, the undersigned certifies that the statements set forth in this instrument are true and correct.
45. Please Type Name in Space Below to Sign*
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47. 1. Receive an email copy of this form.
48. Email address

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