HPD Form 110
Citizen Complaint Form
Your Name: __________________________ _____ Daytime Phone #:____________________
Email Address:______________________________ Cellular Phone #:___________________
Date of Birth:_________________ Social Security Number:__________________________
Address: Street_________________________City___________________State____ZIP_________
Incident Information:
Date of Incident: ______________________ Approximate Time: ______________
Location: ____________________________________________________________________
Details of Complaint:___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
* If additional space is needed, please use a separate Citizen Complaint Narrative Form
Name of Officer(s)/ Employee(s) involved: *___________________*__________________
*_______________________*________________________*_________________________
Description of employee(s) if name is not known
Sex___ Race____ Height_____ Weight______ Hair color_______ Eye Color_________
Vehicle Number or description__________________________________________________
Uniform or Clothing Description_________________________________________________
Witnesses:
Name: ________________________________ Daytime Phone #: ______________________
Email Address:____________________________Cellular Phone #: _____________________
Witness Address: Street____________________City_________________State___ZIP________
Signature of Complainant: _______________________________________Date: __________
Note: Any intentionally false or misleading accusations, statements, or allegations made against Department
employees may lead to civil or criminal action against the complainant.
Department Use Only:
Person Receiving Complaint: _____________________________________Date: _________
Assigned To: __________________________________________________Date: _________
Updated 10/07/2019
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