911 Citizen Complaint Form

CCRCC / CITIZEN COMPLAINT FORM

Employee’s Name - (If Known)

Control Number

Complainant’s Name

Home Address

Home Telephone

Witnesses / Other Complainants

Home Address

Home Telephone

Date / Time of Incident

Location of Incident*

Details of the Complaint*

Name of the Person Assisting*

Signature of the Complainant*

Reason for Assistance:

Date and Time:*

AFFIRMATION (state your Name)*

AFFIRMATION I,(state name in required field), do hereby affirm that the foregoing information provided by me is true and correct to the best of my knowledge and belief. I understand that any false, misleading, or untrue statements, accusations or allegations made by me, either orally or in writing to any person (s) investigating this complaint may subject me to civil prosecution. I realize that it may become necessary during the investigation of this complaint for me to meet with representatives of the Cumberland County Regional Communications Center to discuss this complaint, either in the presence or absence of the accused department member (s) at the discretion of the department. I hereby accept the premise that if any action is initiated through a court or administrative proceeding as a result of my complaint, my testimony before these hearings may be required. I agree to make myself available as a witness before either of the aforesaid bodies, upon request by the Director or his/her designee.

Date of Signing Affirmation*

Signature of Complainant*