Fill - Free fillable Citizen Complaint Sworn Affidavit (City of Stafford, TX) PDF form

Stafford Police Department

Citizen Complaint

Sworn Affidavit

(Use separate page if necessary)

Page _____ of _____ Pages Initials: ______ Date: __________

STATE OF TEXAS DATE: _________________

COUNTY OF FORT BEND TIME: _________________

Before me, the undersigned authority, appeared _______________________________________

(Print Affiant’s Name)

who after being duly sworn on his / her oath deposes and says:

My full name is ______________________________. I am ____ years of age, and my date of

birth is ________________. I currently reside at __________________________________, in

(city) ___________________, (state) _________, (zip code) _______________. My home

telephone number is ____________________, and my work number is ____________________.

I can also be contacted at (other number, pager, cell, etc.) ______________________. My

driver’s license or official identification number is ______________________, and my Social

Security Number is __________________.

I HAVE BEEN INFORMED THAT UNDER TEXAS LOCAL GOVERNMENT CODE,

SECTION 614.022 THAT:

To be considered by the head of a state agency or by the head of a fire

department or local law enforcement agency, the complaint must be:

(1) in writing; and

(2) signed by the person making the complaint.

In addition, the Stafford Police Department requires said written statement be under oath.

In order to conduct a complete and thorough investigation of your complaint, we need you

to answer the following questions. Please be as specific as possible.

1. Date of Incident: _______________________ Time of Incident: ______________

2. Location of the Incident (address): _________________________________________

3. Number of Stafford Police Officers / Employees involved: ______________________

List any names, badge numbers, vehicle numbers and / or license plate numbers, and / or

provide physical descriptors of the officer(s) involved:

A. ____________________________________________________________________

B. ____________________________________________________________________

C. ____________________________________________________________________

Department Use Only: Control #: ____________

Stafford Police Department

Citizen Complaint

Sworn Affidavit

(Use separate page if necessary)

Page _____ of _____ Pages Initials: ______ Date: __________

4. Number of witnesses who observed the incident: __________

Provide full names, addresses, phone numbers, and any other identifying data. If there

are no witnesses, please write the word “NONE”.

A. ____________________________________________________________________

B. ____________________________________________________________________

C. ____________________________________________________________________

D. ____________________________________________________________________

E. ____________________________________________________________________

5. Did you sustain any injuries? __________ If yes, please provide the name, address, and

telephone number(s) of any doctor’s office and / or hospital, as well as the date you

received treatment.

________________________________________________________________________

_______________________________________________________________________

(Use separate page if necessary)

6. Did you receive any medical attention? __________ If yes, please provide the name,

address, and telephone number(s) of any doctor’s office and / or hospital, as well as the

date you received treatment.

________________________________________________________________________

_______________________________________________________________________

7. Were you arrested? __________ Were you issued any tickets? __________ If yes to

either question, please list the charges filed and / or citations issued and the disposition.

________________________________________________________________________

_______________________________________________________________________

(Please use additional page if necessary)

Stafford Police Department

Citizen Complaint

Sworn Affidavit

(Use separate page if necessary)

Page _____ of _____ Pages Initials: ______ Date: __________

8. Please give a detailed accounting of what happened.

(Note: You may type / write your statement out without using this form page if desired)