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.
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(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.
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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.
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(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)
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(Use additional pages if necessary.)
Stafford Police Department
Citizen Complaint
Sworn Affidavit
(Use separate page if necessary)
Page _____ of _____ Pages Initials: ______ Date: __________
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(Use additional pages if necessary.)
Stafford Police Department
Citizen Complaint
Sworn Affidavit
(Use separate page if necessary)
Page _____ of _____ Pages Initials: ______ Date: __________
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(Use additional pages if necessary.)
I have completed ______ years of school and can read and write the English language. I have
read this statement in its entirety and certify that it is correct and true to the best of my
knowledge.
______________________________ ______________________________
(Printed Name) (Signature)
Subscribed and sworn to before me this ______ day of ________________, _____.
Notary Signature: ______________________________
(Notary Stamp / Seal)
(NOTE: A typed or hand-written statement may be attached in lieu of section 8 of this document.
However, the document must be dated and signed in the presence of a Notary Public.) All pages
of this statement must be dated and initialed.