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2. Your name
4. Your street address
5. City, state, zip code
7. Cell number
8. Home number
9. Work number
11. Email address
13. Witness 1 name
15. Witness street address
16. City, state, zip code
18. Witness 2 name
20. Witness 2 street address
21. City, state, zip code
23. Date of occurrence
24. Time of occurrence
26. Place of occurrence
28. Name of officer(s) - (if unknown, include physical description)
30. Badge number(s)
31. Squad number(s)
33. Citation or case number
34. Has this concern been made previously? If so, to whom?
36. Please describe your concern
    Please include all relevant information: the reason you had contact with the Police Department employee or representative, and a narrative of the events. If needed, you may include additional pages below. Include copies of any supporting documents you may have. Please sign and date all pages before uploading them.
38. Upload additional pages or documents
    (All pages or documents must be signed and dated)
40. Date
    Date
41. Your signature*

    Notice: Persons who knowingly provide false information may be subject to criminal prosecution by this agency and civil prosecution by the named employee. Checking the box below will serve as your electronic signature.

    1. Signature
43. Minnesota Government Data Practices Act*

    Pursuant to the Minnesota Government Data Practices Act, you should be aware that any information that you provide will be used to determine whether an applicable law or City policy violation has occurred and whether discipline or other action should be imposed as a result of that action or inaction. Your action in providing this initial report is voluntary however you may be contacted to provide further information in order to move the review of the information forward. Failure to provide accurate contact information may result in the City being unable to further process your concern. In addition and except as limited by the Government Data Practices Act, this information may be made available to the public upon final disposition of the present matter.

    1. I have read this information about the Minnesota Government Data Practices Act
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

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