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MOUNT AIRY POLICE DEPARTMENT POLICE COMMENDATION OR COMPLAINT (Town of Mount Airy)

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The MOUNT AIRY POLICE DEPARTMENT POLICE COMMENDATION OR COMPLAINT (Town of Mount Airy) form is 4 pages long and contains:

  • 1 signature
  • 52 check-boxes
  • 111 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Mount Airy

BROWSE TOWN OF MOUNT AIRY (MD) FORMS

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Page 1 of 4
MOUNT AIRY POLICE DEPARTMENT
POLICE COMMENDATION OR COMPLAINT FORM
INSTRUCTIONS: Complete both pages of this form, including the Narrative Section beginning on page 3. Please print legibly.
Complete all items to the best of your knowledge. Missing or incomplete information may result in delays. Attach any copies of
documentation that may be relevant to your complaint/commendation. Please notify us immediately if you have a change of
address, phone number, or there are changes to your complaint/commendation.
I. PERSON COMPLETING THIS FORM
Do you need an interpreter:
Yes
No
If Yes, in which language?
1. Name (First, MI, Last)
Anonymous Complaint/I do not want to
share
my name or personal information (Skip
to Officer Information Section, page
2.)
2. Home Address
Same as Mailing
Yes
No
3. City
4. State
5. Zip
6. Date of Birth (MM/DD/YYYY)
7. Age
9. Gender/Gender Identity
10. Contact Number
Mobile Home Other
11. Other Contact Number
Mobile Home Other
12. Email Address
13. Location of Incident
14. Date of Incident (MM/DD/YYYY)
15. Time of Incident
A.M.
P.M.
16. Were you directly involved in the
incident?
Yes No
17. Were you arrested during the
incident?
Yes No
18. Did you receive a ticket and/or summons
for this incident?
Yes No
19. Were you physically injured during this
incident?
Yes No
20. If physically injured, was medical attention provided?
Yes No
21. If physically injured, please briefly describe the injury and how it occurred in this box and in the Narrative Statement, which begins
on Page 3:
_
II. VICTIM INFORMATION
(If different from person completing this form)
22. Victim’s Name (First, MI, Last)
The
person completing this form is the victim.
(Skip to Officer Information Section, page 2.)
23. Home Address
Same as Mailing
Yes No
24. City
25. State
26. Zip
27. Date of Birth (MM/DD/YYYY)
28. Age
29. Race/Ethnicity
30. Gender/Gender Identity
31. Contact Number
Mobile Home Other
32. Other Contact Number
Mobile Home Other
33. Email Address
MD
Maryland
Maryland
21157
Page 2 of 4
III. OFFICER INFORMATION
(To the best of your knowledge)
34. Officer’s Name (First, MI, Last)
35.
On Duty
Off Duty
Unknown
36.
Uniformed
Plainclothes
37.
Marked Vehicle
Unmarked Vehicle
Other
39. Age
40. Race/Ethnicity
41. Gender/Gender
Identity
42. ID#
43. Rank
IV. WITNESS INFORMATION (If applicable)
45. Witness’s Name (First, MI, Last)
46. Home Address
Same as Mailing Yes No
47. City
48. State
49. Zip
50. Date of Birth (MM/DD/YYYY)
51. Age
52. Race/Ethnicity
53. Gender/Gender Identity
54. Contact Number
Mobile
Home
Other
55. Alternate Contact Number
Mobile
Home
Other
56. Email Address
V. MEDIATION
Are you interested in mediating this complaint?
Mediation offers a safe space for complainants and police officers to discuss and
resolve the complaint in a fair and impartial way by creating understanding and actively participating in finding a solution.
Please be advised, if mediation is successful, no disciplinary action will be taken against the police officer.
57.
Yes, I am interested in
mediating this complaint
58. No, I am not interested in
mediating this complaint
59.
I do not know/I need more
information about mediation
VI. SIGNATURE OF PERSON COMPLETING THIS FORM
I understand that this statement will be submitted to the Mount Airy Police Department will be the basis for an investigation.
The facts contained in my narrative statement are true to the best of my knowledge and belief. In addition, I declare and affirm
that I have given my statement voluntarily and without persuasion, coercion, or promise of any kind.
Please Print Name: __________________________________________________
Signature: _________________________________________________________ Date: ________________________
click to sign
signature
click to edit
Page 3 of 4
POLICE COMMENDATION OR COMPLAINT FORM
Narrative Statement
To the best of your ability, please write what happened, when it happened, where it happened, who
was involved, how it happened, and why you believe it happened. Also include the outcome you want
to see. Please do not leave any detail out of your statement. If you are making a
commendation:
Which officer would you like to commend, and why? Please do not leave anything out of your
statement.
Page 4 of 4
POLICE COMMENDATION OR COMPLAINT FORM
Narrative Statement (Continued)
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MOUNT AIRY POLICE DEPARTMENT POLICE COMMENDATION OR COMPLAINT (Town of Mount Airy)

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Completed 14 July 2020

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