Complaint Form - Fort Lauderdale [PDF]

ENFOMASYON SOU VIKTIM / TEMWEN. Did you witness this incident? Èske out e wè lè aksyon yo pote plent pou li a rive? Y

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Email - Imèl

Print - Ekri an lèt detache Fort Lauderdale Police Department Office of The Chief 1300 W. Broward Blvd. Fort Lauderdale, FL 33312 (954) 828-5700

Police Employee Recognition/Complaint Form Fòm Pou Pote Plent

Please provide as much information as possible about the incident(s). Use additional pages if necessary. Tanpri bay plis enfòmasyon ou kapab sou aksyon ki pase a (yo). (Sèvi ak lòt fèy papye an plis, si w bezwen).

A. REPORTING CITIZEN’S INFORMATION ENFÒMASYON SOU MOUN KI POTE PLENT LAN

Name:

Date of Birth:

Non:

Dat nesans:

Address:

City:

Adrès:

Zip Code:

Home Phone:

Kòd postal

Telefòn lakay:

Business Phone:

State:

Vil:

(

(

)

Eta:

Cellular: Selilè:

E-mail: imèl :

)

Telefòn Biznis:

Best Time to Contact: Pi bontanpouKontakte

B. INFORMATION ABOUT THE EMPLOYEE(S) INVOLVED IN THE INCIDENT ENFÒMASYON SOU AJAN LAPOLIS KI FÈ AKSYON AN (YO)

Name:

Badge #:

Vehicle #:

Non:

Nimewo badj:

Nimewo oto:

Please provide a physical description of the employee: Deskripsyon fizik ajan lapolis la:

Name:

Badge #:

Vehicle #:

Non:

Nimewo badj:

Nimewo oto:

Please provide a physical description of the employee: Deskripsyon fizik ajan lapolis la:

Name:

Badge #:

Vehicle #:

Non:

Nimewo badj:

Nimewo oto:

Please provide a physical description of the employee: Deskripsyon fizik ajan lapolis la:

Page 1 of 3 Fèy 1 nan 3

Rev. (6/15) Eng/Cre

(

)

     

     

Did you witness this incident?

Yes

No

Èske out e wè lè aksyon yo pote plent pou li a rive?

Wi

Non

C. VICTIM/WITNESS INFORMATION ENFOMASYON SOU VIKTIM / TEMWEN  

 

   

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):

Parent  

Spouse  

Relative

Guardian

Child

Friend

Other

Papa oswa   Manman

Mari oswa   Madanm

Fanmi

Responsab

Pitit

Zanmi

Lòt relasyon

 

 

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::

 

Victim/Witness #1 Viktim/Temwen nimewo 1  

     

Is this person a: victim

witness

Moun sa a se yon:

temwen

viktim

 

Name: Non:  

Address: Adrès:  

 

 

 

   

City:

State:

Vil:

Eta:

Telephone:

  Zip Code:

(

Telefòn:

Kòd postal:

)

 

Victim/Witness #2 Viktim/Temwen nimewo 2  

 

Is this person a: victim

witness

Moun sa a se yon:

temwen

viktim

 

Name: Non:  

Address: Adrès:  

 

 

 

   

City:

State:

Vil:

Eta:

Telephone:

  Zip Code:

(

Telefòn:

Kòd postal:

)

 

Victim/Witness #3 Viktim/Temwen nimewo 3  

 

Is this person a: victim

witness

Moun sa a se yon:

temwen

viktim

 

Name: Non:  

Address: Adrès:  

  Zip Code: Kòd postal:

 

 

 

   

City:

State:

Vil:

Eta:

Telephone: Telefòn:

(

)

  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.  

Page 2 of 3 Fèy 2 nan 3

 

Rev. (06/15) Eng/Cre

D. INFORMATION ABOUT THE INCIDENT ENFÒMASYON SOU AKSYON KI RIVE A  

Please provide as much information as possible, using additional pages if necessary. Bay plis enfòmasyon ou kapab, epi sèvi ak lòt fèy papye ankò si w bezwen.

 

Time:

Date: Dat:

Lè:

 

Location: Kote sa rive:  

Case Number if applicable: Nimewo dosye, si genyen:  

                                                                             

Reporting Citizen’s Signature

Date

Siyati moun ki pote plent lan

Dat

   

For Official Use Only

   

Pou sevi ofisyèl selman

 

Case #:

Date:

Received by:

Date:

Assigned to:  

  Page 3 of 3 Fèy 3 nan 3

 

Rev. (06/15) Eng/Cre

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