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Police Encounter Complaint Form
South Dade Branch South Dade NAACP
Police Encounter Complaint Form
Please enable JavaScript in your browser to complete this form.
–
Step
1
of 3
Instructions: Please fill out this form with as much detail as possible. Attach any relevant documents (photos, videos, etc.) to support your complaint.
Contact Information
Full Name:
*
First
Middle
Last
Date of Birth
Gender
Address
Address Line 1
Address Line 2
City
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Tennessee
Texas
Utah
Vermont
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State
Zip Code
Cell Phone Number
*
Home Phone
*
Work Phone Number
Email Address
*
Preferred Contact Method:
Choose one
Phone:
Email
Mail
NEXT: INCIDENT DETAILS
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2. ABOUT YOUR INCIDENT
Incident Date / Time
Date
Time
Location of Incident
(Address/Area):
Police Department Involved
Name(s) or Badge Number(s) of Officer(s) Involved
(If known)
3. NATURE OF COMPLAINT
Click continue to complete your Complaint information.
Type of Complaint
Choose one
Excessive Force
Harassment
Racial Profiling
Unlawful Search/Seizure
Discrimination
Other
Other (Please specify)
– Description of Incident:
(Be as detailed as possible):
4. WITNESSES
Were there any witnesses to the incident?
Choose one
Yes
No
Witness 1: Please provide details
Witness 1: Provide us name of witnesses, contact information & statement
Witness 2: Please provide details
Witness 2: Provide us name of witnesses, contact information & statement
5. EVIDENCE
Were there any witnesses to the incident?
Choose one
Yes
No
File Upload any supporting documents
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Files supported: (.png, .gif, .jpg) | Documents: (.doc, .xls, .ppt, .pdf) Audio: (.wav, .mp3, .mp4) Video: (.mpg, .mov, .wmv)
Do you have any evidence supporting your complaint (Photos, Videos, Documents)?
Choose one
Yes
No
If yes, please describe the evidence
Please provide any additional information you feel is relevant to your complaint
Additional Information
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7. DECLARATION
I, the undersigned, declare that the information provided is true and accurate to the best of my knowledge. I understand that submitting false information is a criminal offense. A copy of this complaint will be emailed to the Miami-Dade Police Department Police Compliance Bureau (pcbinfo@mdpd.com), you the complainant, and the NAACP South Dade Branch Legal Redress Committee for review.
I,
*
do hereby authorize the South Dade branch of the NAACP to investigate my complaint and to take any steps necessary to resolve it. I understand that the South Dade Branch of the NAACP does not provide legal assistance and is not acting as my attorney in this matter.
Complaintant's Signature
Clear Signature
Print Full Name
Date / Time
Date
Time
Witness Signature
Clear Signature
Date / Time
Date
Time
Upload any additional supporting documentation here
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Files supported are: .pdf, .docx, .doc, .jpeg, .png, .mp4 (file size limit is 5 MB)
Click Here to Submit Your Complaint Form
