Please enter your information (Labels with an "*" are required information.) Last Name * First Name * M. I. * Street Address * City * State Zip Code * Home Phone Number (703-999-9999)* Work Phone Number (703-999-9999)* E-Mail Address * Please enter witnesses information Witness 1: Last Name First Name M. I. Home Phone # Street Address City State Zip Code Work Phone # Witness 2: Last Name First Name M. I. Home Phone # Street Address City State Zip Code Work Phone # Witness 3: Last Name First Name M. I. Home Phone # Street Address City State Zip Code Work Phone # Please enter the officer(s)/employee(s) names and/or descriptions Please enter the incident information Location of Incident Date of Incident (mm/dd/yyyy) Time of Incident (hh:mm) State your specific complaint(s) and explain the circumstances, giving the relevant facts known to you. Affirmation I, , do hereby affirm that the foregoing information provided by me is true and complete to the best of my knowledge and belief. I realize that to assure a thorough investigation of this matter, it may become necessary for me to meet with representatives of the Fairfax County Police Department for the purpose of discussing the incident in detail. I further understand that if a trial board hearing, court hearing or civil service commission hearing results from this investigation, my presence and testimony at such hearing may become necessary. I hereby agree to make myself available at reasonable times and places as may be necessary for such interviews and/or hearings. Reported on . (Enter today's date as mm/dd/yyyy)
