Civil Assault and Battery Complaint Intake Form

Complainant Full Name

First NameLast Name

Preferred Contact Method

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of Incident

Date

Time of Incident

Hour Minutes

AM/PM Option

Incident Location (Address or Description)

Relationship to the Other Party

Other Party Name (if known)

Description of What Happened

Injuries or Damages Suffered

Witnesses (Names and Contact Information, if known)

Have you reported this incident to the police or any other authority?

Evidence Available (photos, messages, video, documents, etc.)

Upload Evidence Files (if available)

Did you seek medical attention?

Desired Outcome or Requested Resolution

Additional Notes (optional)