Complaint Form

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Date

Complainant's Name

Complainant's Address

City

State

Zip Code

Phone Number

Email

Type of Complaint or Allegation

Location of Occurrence

Date of Occurrence

Time

Employee(s) Alledgedly Involved

WITNESS

Name

Address

Phone

Name #2

Address #2

Phone #2

Description of Allegation/Statement of Complaint

Affirmation of Statement

I do hereby affirm that the foregoing information is true and complete to the best of my knowledge and belief. I understand that any false, misleading, or untrue statements or writing to any person(s) examining this complaint, may subject me to civil prosecution by the accused.

I further realize that it may become necessary, during the inquiry of this complaint, for me to meet with a town official, police officer or the Town’s attorney to discuss this complaint; either in the presence or absence of the accused individual at the discretion of the officials involved in this matter.

Complainant's Signature

Clear

For office use only. Do not fill out.

Incident Report #

Incident Received By

Incident Report Received on

Reviewed By

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Need Assistance With Your Form?

For any questions or assistance with the incident form, please contact the Summitville Town Office at 765-536-2802. Our dedicated team is here to assist you every step of the way. Thank you for your cooperation and commitment to making Summitville a great place to live and work!

Complaint Form

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