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2. Internal Affairs Report Form
   Person Making Report (Optional, But Helpful)
4. First Name
5. Last Name
6. Date of Birth
   Date of Birth
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Email Address
16. Preferred Contact

    1. Phone
    2. Email
20. Officer(s) Subject to Allegation
    Provide Whatever Info is Known
22. Officer(s) Names
23. Badge No.
25. Incident Location
26. Date/Time
    Date/Time

    Date/Time
28. In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct. If you do not know the officer’s name or badge number, provide any other identifying information.
32. Any physical evidence submitted?

    1. Yes
    2. No
33. If yes, describe
35. Was incident previously reported?

    1. Yes
    2. No
36. If yes, describe
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field