Citizen Commendation / Concern Form

2. Your Name
3. Date of Birth
   Date of Birth
5. Street Address
6. Address Line 2
8. City
9. State / Province / Region
11. ZIP / Postal Code
13. Home Phone
14. Work Phone
16. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
18. Location of Incident
20. Please describe the incident*
22. If applicable, please provide the name(s) of Deputy/Employee(s) involved.
24. Name of Witness
25. Witness Phone Number
27. Street Address
28. Address Line 2
30. City
31. State / Province / Region
33. ZIP / Postal Code
35. Name of Witness
36. Witness Phone Number
38. Address
39. Address Line 2
41. City
42. State / Province / Region
44. Zip / Postal Code
46. If applicable, were you cited/arrested?

    1. Yes
    2. No
47. Court Date
    Court Date
49. What were you cited/arrested for?
51. Form Agreement*

    1. By signing, I swear the information I have given is true. I have been informed that in some cases, I may be asked to submit a polygraph examination as part of the investigation, and I agree to c
53. Name of Reporting Party*

    Please type your name below to confirm you agree to the above terms.

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field