POLICE COMPLAINT/COMMENDATION FORM*

Independent Police Review Division
1221 SW 4th Avenue, Room 320 Portland, Oregon 97204-1987
Phone: (503)823-3530 Fax: (503)823-3530


I WISH TO FILE A (Please Pick One):
   
Information About You  
(Note: Required fields are marked by an *)  
First Name:*
Last Name:*
Date of Birth:* (i.e. 12/21/1960 for Dec. 31, 1960)
Gender:*
Race/Ethnicity:
   
Your Address Information  
Street Address:*
Apt. Number:
City:*
State:*
Zip Code:*
Email:
   
Your Phone Information (Please enter all that apply)    
Home Phone: ()
Work Phone:  ()
Cell Phone: ()
Message Phone: ()
   
Third Party and Attorney Information  
Are you filing this information on behalf of someone else*
   
IF YES, please write his/her name, address and phone number:  
 
   
Are you currently represented by an attorney relating to the
subject matter of your complaint?*		  
IF YES, what is your attorney's name?  
What is your attorney's phone number? ()
     
Information About The Incident    
Location of the incident:*  
Date of the incident: (i.e. 12/31/2001 for Dec. 31, 2001)  
Time of incident: (i.e. 08:20)  
   
     
Names and badge numbers of officers involved
(if known):		    
   
     
Names, addresses and phone numbers of witnesses
(if known):		    
   
     
Statement or Description of Incident    
Please write a brief description of the incident below:*