Citizen’s Complaint Form

IRCSO USE ONLY
Complaint Number:

Date and Time Reported:   	

Complainant:

Name:	Date of Birth:	Sex:  	

Home Address:	Phone:  	

City, State, Zip Code:  	

Business Address:	Phone:  	

City, State, Zip Code:  	

Complaint:

Date and Time of Incident:   	

Location of the Incident:  	

Nature of the Complaint:  	

Arrest/Accident/Incident Number (If Known):  	

Witness:	Phone:  	

Address:  	

Witness:	Phone:  	

Address:  	

Agency Personnel Involved:

Name:	Title: 	

Name:	Title: 	

Complainant’s Signature:	Date: 	

Citizen’s Complaint Form

Supplement
(This section may be used by you and/or the agency to summarize or further your complaint.) Additional Information:   	

IMPORTANT, READ AND SIGN THE FOLLOWING INFORMATION

I,	hereby certify and affirm that the statements contained herein are true and correct. I further certify and affirm I make these statements subject to the penalties outlined in Florida Statute 837.02 and Florida Statute 837.06.

837.02 Perjury in official proceedings (1) Except as provided in subsection (2), whoever makes a false statement, which he or she does not believe to be true, under oath in an official proceeding in regard to any material matter, commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
837.06 False official statements (2) Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

I have read and understand the above statement

Signature	Print Name

STATE OF FLORIDA
COUNTY OF 	
Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization, this day of	, 20	,by  	

(Signature of Notary Public ‐ State of Florida)

 	Personally Known OR	Produced Identification

(Print, Type, or Stamp Commissioned Name of Notary Public)

Type of Identification Produced