Labels with an asterisk (*) are required information. Please enter your informationLast 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 * Witness 1Last Name First Name M. I. Street Address City State Zip Code Home Phone # Work Phone # Witness 2Last Name First Name M. I. Street Address City State Zip Code Home Phone # Work Phone # Witness 3Last Name First Name M. I. Street Address City State Zip Code Home Phone # Work Phone # Officer/Employee InformationPlease enter the officer(s)/employee(s) names and/or descriptions Incident InformationLocation 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. AffirmationI, , 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)
