I wish to recognize exceptional service
I wish to make a complaint
NLRPD Citizen Communication Form
For Office Use Only
IA Number:
SGT and LT Assignment:
Report Date:
YOUR NAME
I wish to remain anonymous
Name
Home Address
Home Number
Work Number:
Cell Phone Number:
Address of Contact with Officer:
Date and approximate time of contact:
If this incident was a traffic stop, did you receve a ticket?
No
Yes
If so,what was the charge?
Were you arrested during this incident?
No
Yes
What was the charge?
INCIDENT
Officer's Name
(if known)
Assisting Officer's Name
(if known)
Witness Name
Witness Name
Witness Address
Witness Address
Home Phone
Work Phone
Home Phone
Work Phone
Please describe the specific allegation or incident and explain in detail: