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2. YOUR INFORMATION
   Please provide your contact information.
4. Name*
5. D.O.B.
7. Address*
9. Best Phone Number to Call
10. Best Time to Call
11. Email Address
13. WITNESS INFORMATION
    Please provide contact information for any witnesses.
15. Name
16. Address
17. Phone Number
19. Name
20. Address
21. Phone Number
23. Name
24. Address
25. Phone Number
27. OFFICER / EMPLOYEE INFORMATION
    Please provide the names of the officer(s) or employee(s) involved.
29. Name
30. Name
32. Name
33. Name
35. If you do not know the names of the employees or officers, please provide comments here:
37. INCIDENT DETAILS
    Please provide information regarding the incident.
39. Date of Incident
40. Time of Incident
41. Case Number (if known)
43. Location of Incident (address or description)
45. Narrative (please provide a detailed summary of your complaint)
47. What is your desired outcome?
49. SIGNATURE AND ACKNOWLEDGEMENT
    By signing this form, I acknowledge that the information I’ve provided is true and correct to the best of my knowledge. I understand that it is a criminal offense to make a false statement to a member of the police department, pursuant section 76-8-503 and/or 76-8-504, of the Utah Criminal Code. I understand that digital signatures are considered legal in the State of Utah.
51. Signature /S/
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53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field