CITIZEN COMPLAINT FORM If you would rather print out & return, please click here to download the form.COMPLAINT INFORMATIONDate MM slash DD slash YYYY Full Name Last First Middle Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address(If different from Home) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone NumberWork Phone NumberCell Phone NumberOther Phone NumberEmail Address RaceSex Male Female Date of Birth Month Day Year AgePlease enter a number from 1 to 119.INCIDENT INFORMATIONDate MM slash DD slash YYYY TimeIncident LocationLocation Type Business Residence Hwy/Roadway Name of BusinessName & Badge Number of Deputy(s) InvolvedBadge #Name of Deputy Was a supervisor requested at the scene? No Yes Did the supervisor arrive at the scene? No Yes Was anyone arrested related to this incident? No Yes Did the incident result in your arrest? No Yes Case Number of IncidentList All Charges, If You Were Arrested Specific AllegationsDescribe in detail the complaint you have involving a Rockdale County Sheriff’s Office employee, and include the actions of that employee that resulted in this complaint.Are you be willing to submit to a polygraph examination regarding the information contained in your complaint? No Yes SWORN AFFIDAVIT OF COMPLAINTI,, do swear and affirm that all statements and information relayed in this document, as well as those given verbally to any representative of the Rockdale County Sheriff’s Office, are true and correct to the best of my knowledge and belief. I also understand that any knowingly false statement and/or accusations made by me can be used for prosecution under Georgia law (O.C.G.A. § 16-10-17) that reads: (a) A person to whom a lawful oath or an affirmation has been administered or who executes a document knowing that it purports to be an acknowledgment of a lawful oath or affirmation commits the offense of false swearing when, in any matter or thing other than a judicial proceeding, he knowingly and willfully makes a false statement. (b) A person convicted of the offense of false swearing shall be punished by a fine of not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.Complainant/Affiant NameComplainant/Affiant SignatureDate MM slash DD slash YYYY Witness NameWitness SignatureDate MM slash DD slash YYYY
