Citizen Complaint/Compliment Form 05/2020
DES MOINES POLICE DEPARTMENT
Citizen’s Complaint
Citizen’s Compliment
(DMPD Use Only)
Date Complaint Received
Complaint Registry Log Number
CITIZEN’S INFORMATION
Please provide your contact information but complaints and/or compliments may be made anonymously
Name:
Address:
City:
State:
Zip:
Day Phone:
Evening Phone:
INFORMATION ABOUT INCIDENT
Date of Contact/Incident:
Location of Contact/Incident:
Police Case Number (If Applicable):
WITNESS(ES) INFORMATION
Name:
Contact #
Name:
Contact #
Name:
Contact #
EMPLOYEE(S) INFORMATION
Name:
ID #
Name:
ID #
Name:
ID #
Citizen Complaint/Compliment Form 05/2020
DETAILS ABOUT THE INCIDENT OR ACTION
(May Attached Additional Pages if Needed)
RECOMMENDATIONS
(What Would You Like To See Happen)
FOLLOW UP & DECLARATION
Would you like to be contacted by the employee(s) supervisor? Yes No
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct. (RCW 9A.72.085)
Signature of person completing form: _________________________________________________
Completed forms may be delivered or mailed to:
Des Moines Police Department
21900 11 Avenue South
Des Moines, WA 98198
Attention: Professional Standards Sergeant
Receiving Supervisor:
Employee(s) Supervisor:
Date Received:
(DMPD Use Only)
click to sign
signature
click to edit
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