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2. 
4. Today's Date:
7. Full Name:
8. Date of Birth:
10. Social Security Number:
11. Street Address:
13. City, State:
14. Zip Code:
15. Home Phone #:
17. Cell Phone #:
18. Work Phone #:
19. Email Address:
21. Under Texas Government Code Section 614.022, Complaints against a peace officer must be submitted in writing and signed by the person submitting the complaint.
23. I order to conduct a complete investigation of your complaint, please answer the following questions truthfully and specifically.
25. Date of Incident:
26. Time of Occurrence:
28. Location of Incident:
30. List Names, Badge Numbers, Descriptions of Officers or Vehicle Numbers Involved:
32. List of Witnesses Involved. Provide Full Name, Addresses, Phone Numbers. Or write "NONE" if no witnesses:
34. _____ I was injured as a result of this incident.
36. _____ I was NOT injured as a result of this incident.
38. If injured, please list the type of injuries and how the injuries were sustained:
40. _____ I received medical attention for the injury.
42. List the date, name, address, and phone numbers od medical treatment providers:
44. Were you arrested?
46. Initials: __________ Date: ____________________
48. Were you issued a ticket?
50. If you answered "yes" to the above, please list the charges or citations issued:
52. Detailed statement of what happened and nature of complaint: (Note: May be handwritten and attached)
54. The filing of a formal complaint against an employee of the Nassau Bay Police Department by you instituts an administrative investigation which could result in the disciplinary action being taken against the employee(s).
56. Therefore, a person who makes a false statement under oath concerning a complaint filed (as required by Section 614.022, Texas Government Code) against a law enforcement officer, with intent to deceive and with knowledge of the statement's meaning, is guilty of Aggravated Perjury under Section 37.03 of the Texas Penal Code, if the person has knowledge of the content of the complaint, the purpose of it's filing, and the official character of the investigation conducted in connection therewith, and if the statement is material.
58. I acknowledge that I have read the above notification prior to or at the conculsion of my statement. I can read and write the English language and solemnly swear that this statement which I have made and which I hereby affix my signature to is true and correct to the best of my knowledge and belief.
60. ***DO NOT SIGN AT THIS TIME***
62. This document must be signed in the presence of a Notary Public provided by the Nassau Bay Police Department.
64. Name:
    Printed
66. Signature Before Notary _________________________________________________________________________________
68. Subscribed and sworn to before me this __________ day of _________________________________, 20________.
70. Notary Signature _________________________________________________________________________________
72. Notary Stamp/Seal
74. Print this form and hand deliver to:
76. Nassau Bay Police Department
    1800 Space Park Dr., Suite 200, Nassau Bay, Texas 77058
78. Under the Texas Government Code 614.023, a signed copy of this complaint must be given to the law enforcement officer within a reasonable time.
80. Initials: __________ Date: ____________________
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81. Print Only

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