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2. Citizen Complaint Form

   The Roosevelt City Police Department is committed to serving the community in a highly professional manner and supports a readily available process by which citizens and employees can have confidence that complaints against either employees or the Department will be fairly and thoroughly investigated. Such investigations will ensure that proper corrective actions are taken, when appropriate, as well as protect employees against unwarranted criticisms when the procedures or actions by the employees or Department were proper.

   The Roosevelt City Police Department acknowledges the responsibility it has to accept and investigate all complaints brought to the attention of the Department and is committed to resolving those complaints. Furthermore, the Department is also committed to taking appropriate action, when necessary, against those employees involved in unacceptable behavior or actions of misconduct, including training, counseling, or an appropriate level of discipline.

4. NOTICE

   Pursuant to section 76-8-504.4, Utah Code Annotated, you are notified that statements you are about to make may be presented to a magistrate or judge in lieu of your sworn testimony at a preliminary examination. Any false statement you  make and that you do not believe to be true may subject you to criminal punishment as a Class A Misdemeanor. 

6. First Name*
7. Last Name*
9. Date of Birth
   Date of Birth
11. Address
13. City
14. State
15. Zip Code
17. Phone Number*
18. Email Address*
20. Complaint/ Allegations Against (Employee Name)
21. Date of Occurrence
    Date of Occurrence Start Date

    —

    Date of Occurrence End Date
23. Summary of Complaint/ Allegations *
25. Witness Name (if applicable)
26. Witness Phone Number
28. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field