Fillable ADMINISTRATIVE COMPLAINT FORM (Pueblo of Santa Ana)

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ADMINISTRATIVE COMPLAINT FORM (Pueblo of Santa Ana)

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SANTA ANA POLICE DEPARTMENT
ADMINISTRATIVE COMPLAINT FORM
FOR OFFICE USE ONLY
DATE REPORTED:________TIME REPORTED:_______ RECEIVED BY:__________
NAME:_____________________________________DATE:___________________
DATE OF INCIDENT:_____________________ TIME OF INCIDENT:____________
LOCATION OF INCIDENT:_____________________________________________
OTHER PERSONS
PRESENT:__________________________________________________________
WARNINGS AND INFORMATION
State of New Mexico Statute 30-39-1:
1) It is unlawful for any person to intentionally make a report to a law enforcement
agency or official, which report he knows to be false at the time of making it, alleging a
violation by another person of the provisions of the Criminal Code (30-1-1 NMSA 1978).
2) Any person violating the provisions of this section is guilty of a misdemeanor.
I UNDERSTAND THAT KNOWINGLY MAKING A MATERIALLY FALSE OR UNTRUE
STATEMENT DURING THE COURSE OF THIS COMPLAINT PROCEDURE MAY
SUBJECT ME TO CRIMINAL OR CIVIL LAW LIABILITY.
I realize that it may become necessary during the investigation of this complaint, for me
to meet with a member(s) of the Police Department to discuss this complaint, either in
the presence or absence of the accused member(s), at the discretion of the department.
I hereby accept and agree that if any action is initiated through a court or administrative
hearing as a result of my complaint, my testimony before these hearings may be
required. I hereby agree to make myself available to the aforementioned court or
administrative hearing when requested to do so.
I HAVE READ THE ABOVE WARNINGS AND INFORMATION, OR HAVE HAD IT
READ TO ME. I UNDERSTAND IT AND DO HEREBY MAKE THE ATTACHED
PERSONAL STATEMENT VOLUNTARILY AND OF MY OWN FREE WILL.
______________________________________________________________________
Signature of Complainant Witness Signature
Page _____ of _____
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COMPLAINT FORM
CASE # (if known) _____________
EMPLOYEE’S NAME(S): _____________________________________
Person(s) complaint is against) _____________________________________
COMPLAINANT:
LAST NAME:___________________ FIRST:_________________ MI:___ DOB:______
ADDRESS:_________________________________________PHONE(H):__________
CITY:___________________________________STATE:_______ ZIP CODE:_______
EMPLOYER (OPTIONAL):__________________________ PHONE (W):___________
WITNESSES/OTHER COMPLAINANTS (PLEASE IDENTIFY)
(USE REVERSE SIDE IF NEEDED)
1) LAST NAME:___________________ FIRST:_______________ MI:___DOB:______
ADDRESS:_________________________________________PHONE(H):__________
CITY:___________________________________STATE:_______ ZIP CODE:_______
EMPLOYER (OPTIONAL):__________________________ PHONE (W):___________
2) LAST NAME:___________________ FIRST:_______________ MI:___DOB:______
ADDRESS:_________________________________________PHONE(H):__________
CITY:___________________________________STATE:_______ ZIP CODE:_______
EMPLOYER (OPTIONAL):__________________________ PHONE (W):___________
3) LAST NAME:___________________ FIRST:_______________ MI:___DOB:______
ADDRESS:_________________________________________PHONE(H):__________
CITY:___________________________________STATE:_______ ZIP CODE:_______
EMPLOYER (OPTIONAL):__________________________ PHONE (W):___________
4) LAST NAME:___________________ FIRST:_______________ MI:___DOB:______
ADDRESS:_________________________________________PHONE(H):__________
CITY:___________________________________STATE:_______ ZIP CODE:_______
EMPLOYER (OPTIONAL):__________________________ PHONE (W):___________
COMPLAINT (TOPIC OF COMPLAINT)
______________________________________________________________________
______________________________________________________________________
Page _____ of _____
COMPLAINT FORM
Details of the complaint, YOUR SWORN STATEMENT. Be as specific as possible.
(Attach a separate page if necessary to continue)
I HAVE READ THE ATTACHED STATEMENT MADE BY ME, OR HAVE HAD IT READ TO
ME, AND HAVE HAD AN OPPORTUNITY TO MAKE CORRECTIONS TO IT. IT IS A TRUE
AND CORRECT STATEMENT.
____________________________________ ___________________________________
Signature of Complainant AND Date/Time
____________________________________ __________________________________
Name of Person Assisting (if applicable) and the reason assistance was
Page _____ of _____
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ADMINISTRATIVE COMPLAINT FORM (Pueblo of Santa Ana)

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Completed 20 July 2020

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