PFLUGERVILLE POLICE DEPARTMENT

CITIZEN COMPLAINT

1.     My name is

                                                (Last)                                      (First)                                     (Middle)

2. Address

(Street No)             (Street Name)                        (City)                      (Zip Code)            

3.     Home Phone Best times to call between AM/PM and AM/PM

4.     Work Phone Extension

5.     My age is  years.

6. Location of incident

7.    Date of incident Time

8. Employee(s) involved

9.     Were you arrested or issued a citation? Charge:

10.   Were you injured? Describe:

11. Witnesses:

Name                                                                            Address                                                 Phone Numbers

12. State what occurred and your complaint against employee(s):

(attach as many additional sheets as necessary)

Signature of Complainant                                         Signature of Parent/Guardian-if complainant is under

                                                                                      18 years of age.

Mail to:         Pflugerville Police Department

                      Chuck Hooker,  Chief of Police

                      P.O. Box 679

                      1611 E. Pfennig Lane

Pflugerville, Texas 78691-0679

512-251-4004

chooker@cityofpflugerville.com