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2. Complainant Information

   The first section below will be information pertaining to you, the person making the complaint. Please provide as much information as possible.

4. First Name*
5. Last Name*
7. Date of Birth*
   Date of Birth
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Alt Phone Number
17. Email Address*
21. Witnesses/Others

    This section below pertains to any witnesses or others involved that you would like to include information for. Please include as much information as possible.

23. (Witness/Other #1) First Name
24. (Witness/Other #1) Last Name
26. (Witness/Other #1) Date of Birth
    (Witness/Other #1) Date of Birth
28. (Witness/Other #1) Address
30. (Witness/Other #1) City
31. (Witness/Other #1) State
32. (Witness/Other #1) Zip Code
34. (Witness/Other #1) Phone Number
35. (Witness Other #1) Alt Phone
36. (Witness/Other #1) Email Address
40. (Witness/Other #2) First Name
41. (Witness/Other #2) Last Name
43. (Witness/Other #2) Date of Birth
    (Witness/Other #2) Date of Birth
45. (Witness/Other #2) Address
47. (Witness/Other #2) City
48. (Witness/Other #2) State
49. (Witness/Other #2) Zip Code
53. The Incident

    The following questions refer to the INCIDENT IN QUESTION. Please be thorough.

55. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
56. Location of Incident*
58. Person Directly Affected by Incident if Not Complainant
59. Incident # / Case # (if applicable)
61. Officer(s) this Complaint is Regarding
62. Officer(s) Vehicle #s this Complaint is Regarding
64. Do you desire contact from our department in regards to your complaint?

    1. Yes
    2. No
66. Nature of Complaint: Written summary detailing dissatisfaction/allegations

    Please be specific. 

68. Pennsylvania Crimes Code - Electronic Signature Agreement*

    Please understand that it is a violation of the Pennsylvania Crimes Code Title 18 Section 4906 to knowingly give false information to law enforcement. I agree that all information provided on this complaint is true and correct to best of my knowledge. Any omissions, falsehoods, or untrue allegations may subject me to criminal and/or civil prosecution. To acknowledge, please provide your electronic signature.
    
    By checking the "I agree" box below, you agree and acknowledge that by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

    1. I agree.
70. Electronic Signature
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field