Fillable Form 874 Citizen Complaint Form (City of Miami Gardens)

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Form 874 Citizen Complaint Form (City of Miami Gardens)

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The Form 874 Citizen Complaint Form (City of Miami Gardens) form is 3 pages long and contains:

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  • 15 check-boxes
  • 73 other fields

Country of origin: US
File type: PDF

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BROWSE CITY OF MIAMI GARDENS (FL) FORMS

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Miami Gardens Police Department
Professional Compliance Unit
18611 NW 27
th
Avenue
Miami Gardens, FL 33056
Telephone: (305) 474-1678 Fax: (305) 474-1529
Citizen Complaint Form
FÒM POU POTE PLENT/FORMULARIO DE QUEJA
1 | P a g e
Please provide as much information as possible about the incidents(s). Use additional pages if
necessary.
BAY PLIS ENFÒMASYON OU KAPAB SOU AKSYON KI PASE A (YO). (SÈVI AK LÒT FÈY PAPYE AN PLIS, SI W BEZWEN).
POR FAVOR, EMITIR TODA LA INFORMACIÓN POSIBLE SOBRE LOS INCIDENTES (S). PUEDE USAR PÁGINAS ADICIONALES
SI ES NECESARIO.
A. COMPLAINANT INFORMATION
ENFÒMASYON SOU MOUN KI POTE PLENT LAN/DATOS DEL DENUNCIANTE
Name:
NON:
NOMBRE:
Date of Birth:
DAT NESANS:
FECHA DE NACIMIENTO:
Address:
ADRÈS:
DIRECCIÓN:
State:
ETA:
ESTADO:
Business Phone:
TELEFÒN NAN TRAVAY MOUN LAN:
TELÉFONO DEL TRABAJO:
Best Time to Contact:
MEILLEUR TEMPS POUR CONTACTER:
LA MEJOR HORA QUE PODEMOS LLAMAR:
E-mail:
ADRÈS ELEKTWONIK:
CORREO ELECTRÓNICO:
B. INFORMATION ABOUT THE OFFICER(S) INVOLVED IN THE INCIDENT
ENFÒMASYON SOU AJAN LAPOLIS KI FÈ AKSYON AN (YO)/ DATOS DEL (DE LOS) OFICIAL(ES) INVOLUCRADO(S) EN EL INCIDENTE
Officer Name:
OFFICIER NON:
NOMBRE DEL OFICIAL:
Badge #:
NIMEWO BADJ LI:
PLACA NO.:
Vehicle #:
NIMEWO OTO A:
NUMERO DE
CARRO:
Please provide a physical description of the
officer:
DESKRIPSYON FIZIK AJAN LAPOLIS LA:
DESCRIBA LA APARIENCIA FÍSICA DEL OFICIAL:
Officer Name:
OFFICIER NON:
NOMBRE DEL OFICIAL:
Badge #:
NIMEWO BADJ LI:
PLACA NO.:
Vehicle #:
NIMEWO OTO A:
NUMERO DE
CARRO:
Please provide a physical description of the
officer:
DESKRIPSYON FIZIK AJAN LAPOLIS LA:
DESCRIBA LA APARIENCIA FÍSICA DEL OFICIAL:
Officer Name:
OFFICIER NON:
NOMBRE DEL OFICIAL:
Badge #:
NIMEWO BADJ LI:
PLACA NO.:
Vehicle #:
NIMEWO OTO A:
NUMERO DE
CARRO:
Please provide a physical description of the officer:
DESKRIPSYON FIZIK AJAN LAPOLIS LA:
DESCRIBA LA APARIENCIA FÍSICA DEL OFICIAL:
2 | P a g e
C. VICTIM/WITNESS INFORMATION
ENFOMASYON SOU VIKTIM / TEMWEN/DATOS DE LA VICTIMA / TESTIGO
Did you witness this incident?
ÈSKE OUT E WÈ LÈ AKSYON YO POTE PLENT POU LI A RIVE?
FUE USTED TISTIGO DEL INCIDENTE DENUNCIADO?
Yes
WI
SÍ
☐
No
NON
NO
☐
If you are filing a complaint on behalf of someone else, what is your relationship, if any to the
person(s):
SI SE SOU NON YON LÒT MOUN OU VLE POTE YON PLENT, KISA OU YE POU MOUN LAN (YO):
SI USTED ESTÁ PRESENTANDO UNA DENUNCIA EN NOMBRE DE OTRA(S) PERSONA(S), INDIQUE CUÁL ES SU RELACIÓN
CON ESA(S) PERONA(S):
Parent
PAPA OSWA MANMAN
PADRE/MADRE
☐
Relative
FANMI
FAMILIAR
☐
Child
PITIT
HIJO/A
☐
Other
LÒT RELASYON
OTRA:
☐
Spouse
MARI OSWA MADANM
ESOPSO/A
☐
Guardian
RESPONSAB
GUARDIÁN
☐
Friend
ZANMI
AMIGO/A
☐
Please provide as much of the following information as you can about the person(s) on whose behalf
the complaint is filed and any witness (es) to the incident:
BAY PLIS ENFÒMASYON OU KAPAB SOU MOUN OU VLE POTE PLENT SOU NON LI A, AK SOU NENPÒT TEMWEN KIT E WÈ LÈ
AKSYON AN RIVE
POR FAVOR EMITIR TODA LA INFORMACION POSIBLE SOBRE LA (LAS) PERSONA(S) EN NOMBRE DE LA(S) CUAL(ES)
PRESENTA LA DENUNCIA, Y SOBRE EL (LOS) TESITGO(S) DEL INCIDENTE:
Victim/Witness #1 VIKTIM/TEMWEN NIMEWO 1 VÍCTIMA/TESTIGO NO. 1
Is this person a:
MOUN SA A SE YON / ESTA PERSONA ES:
Victim/ VIKTIM /VÍCTIMA
☐
Witness/TEMWEN/TESTIGO
☐
Name:
NON:
NOMBRE:
Address:
ADRÈS:
DIRECCIÓN:
City:
VIL:
CIUDAD:
State:
ETA:
ESTADO:
Zip Code:
KÒD POSTAL/CODIGO POSTAL:
Telephone:
TELEFÒN/ NUMERO DE TELEFONO:
Victim/Witness #2 VIKTIM/TEMWEN NIMEWO 2 VÍCTIMA/TESTIGO NO. 2
Is this person a:
MOUN SA A SE YON / ESTA PERSONA ES:
Victim/ VIKTIM / VÍCTIMA
☐
Witness/TEMWEN /TESTIGO
☐
Name:
NON:
NOMBRE:
Address:
ADRÈS:
DIRECCIÓN:
City:
VIL:
CIUDAD:
State:
ETA:
ESTADO:
Zip Code:
KÒD POSTAL/CODIGO POSTAL:
Telephone:
TELEFÒN/ NUMERO DE TELEFONO:
Victim/Witness #3 VIKTIM/TEMWEN NIMEWO 3 VÍCTIMA/TESTIGO NO. 3
Is this person a:
MOUN SA A SE YON: ESTA PERSONA ES:
Victim/ VIKTIM / VÍCTIMA:
☐
Witness/TEMWEN /TESTIGO
☐
Name:
NON:
NOMBRE:
Address:
ADRÈS:
DIRECCIÓN:
City:
VIL:
CIUDAD:
State:
ETA:
ESTADO:
Zip Code:
KÒD POSTAL/CODIGO POSTAL:
Telephone:
TELEFÒN/ NUMERO DE TELEFONO:
3 | P a g e
If you have more victims/witnesses, please use additional page(s). SI GEN LÒT VICTIM / TEMWEN ANKÒ, SÈVI
AK (YON) LÒT FÈY PAPYE AN PLIS. SI TIENE MÁS VÍCTIMAS/TESTIGOS, POR FAVOR UTILICE PÁGINAS ADICIONALES.
D. INFORMATION ABOUT THE INCIDENT
ENFÒMASYON SOU AKSYON KI RIVE A/ INFORMACIÓN ACERCA DEL INCIDENTE
Date:
DAT/FECHA:
Time:
LÈ/HORA:
Location:
KOTE SA RIVE/LUGAR:
Case Number:
NIMEWO DOSYE, SI GENYEN/ NO. DE CASO, SI CORRESPONDE:
Please provide details of the incident:
S'IL VOUS PLAIT FOURNIR DES DETAILS SUR L'INCIDENT/POR FAVOR DAR TODOS LOS DETALLES DEL INCIDENTE:
For Official Use Only - POU BIWO A SEVI SELMAN - PARA USO OFICIAL SOLAMENTE
Case#
Complaint Received by:
Date:
Assigned to:
Date:
Complainant’s Signature
SIYATI MOUN KI POTE PLENT LAN
FIRMA DEL DENUNCIANTE
Date
DAT/ FECHA
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Form 874 Citizen Complaint Form (City of Miami Gardens)

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Completed 14 July 2020

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