GRAFTON POLICE DEPARTMENT CITIZEN COMPLAINT FORM

GRAFTON POLICE DEPARTMENT CITIZEN COMPLAINT FORM

Phone: 304-265-0101
Complainant's Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Other Phone Number

Area Code Phone Number
Suspect's information:
Suspect's Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Height
Weight
Eyes
Hair
Sex
Race
Other
Date of Offense

Month Day Year
Date
Time of Offense
Law/Ordinance allegedly violated
Witnesses to this incident:
Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Do you have in your possession any physical evidence of this incident?

Yes No
Was there a vehicle involved?

Yes No
If yes, please provide a description of the vehicle involved.
Summary of Complaint: *
If you have any evidence, attach it here. (video, photo, paperwork, etc.)

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Attachment 1 Cancel of
If you have any evidence, attach it here. (video, photo, paperwork, etc.)

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Attachment 2 Cancel of
If you have any evidence, attach it here. (video, photo, paperwork, etc.)

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Attachment 3 Cancel of
Any person who willfully and knowingly provides false or misleading information to any police officer while they are engaged in their lawful duties shall be guilty of a misdemeanor and may be fined up to $500.00 in cash and/or sentenced up to 1 year in jail as defined in the WV Code 61-5-17.

I swear and affirm that the information contained in this complaint is true and correct to the best of my knowledge and ability.
Complainant's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

GRAFTON POLICE DEPARTMENT CITIZEN COMPLAINT FORM

Suspect's information:

Witnesses to this incident: