662-429-9096
fax 662-449-3350
POLICE COMPLAINT FORM
The following form must be
filled in completely before any action will be taken on your complaint. City Council meetings will not be used a public
forum for complaints against Police officers.
Please allow 15 days to receive an answer to your complaint. You must be specific as to the nature of your
complaint. If you are complaining about
an incident that is under investigation, is pending hearing or Trial in any
court, you will only receive a notice stating “Under investigation”. You may not use one form to complain about
multiple incidents. You must fill out a
separate form for each incident in question.
Please be advised, if this complaint is used to affect the employment of
an officer or employee of the city, the officer or employee must be provided
with a copy of this complaint and result of this complaint. Police Policy states that most complaints,
including Racial profiling, will not be considered after 60 days.
Person Making Complaint
______________________________________________________________________________________
Last Name First Name M.I. Sex Race DOB Driver’s
License# & State
______________________________________________________________________________________
Address City State Zip Area
Code & Phone Number
Incident in Question
______________________________________________________________________________________
Date of Incident Time of Incident Officer Involved Report Number
______________________________________________________________________________________
Name of Person directly
affected by this Incident Sex Race DOB Driver’s License# & State
How was this person affected
(Arrested, Citation, Jailed, Injured, Questioned and Released, Other):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What is your standing to make
this complaint (Person affected, Concerned Citizen, Parent, Other):
______________________________________________________________________________________
What did the officer or employee
do that prompted you to make this complaint? (Violated Law, made illegal stop,
used profanity, used unnecessary force, was rude in with public, other):
______________________________________________________________________________________
Witnesses that have direct
knowledge of this incident (If none, please fill in with “NONE” on first line):
______________________________________________________________________________________
Last Name First Name M.I. Sex Race DOB Driver’s
License# & State
______________________________________________________________________________________
Address City State Zip Area
Code & Phone Number
______________________________________________________________________________________
Last Name First Name M.I. Sex Race DOB Driver’s
License# & State
______________________________________________________________________________________
Address City State Zip Area
Code & Phone Number
Action you believe should
take place (Termination, Suspension, Written Warning, etc.):
______________________________________________________________________________________
All Complaints should be
directed to the Chief of Police, James M. Riley. You can set up an appointment to speak with
Chief Riley by calling 662-429-9096, or request to speak with him or leave a
voice message. You can also email him at
mriley@hernandopolice.org.
Please write a brief
narrative of your complaint in the space provided. If more space is needed, please attach. ANY FALSE STATEMENTS MADE MAY BE SUBJECT TO
PROSECUTION UNDER PERJURY, FALSE REPORT OR CIVIL STATUTES.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
UNDER PENALTY OF PERJURY THE
UNDERSIGNED SWEARS THAT THE FACTS CONTAINED ON PAGE ONE, TWO AND ALL
ATTACHMENTS OF THIS DOCUMENT ARE WITHIN THEIR PERSONAL KNOWLEDGE AND ARE TRUE
AND CORRECT.
_______________________________________ ______________________________
Signature of Person Filing
Complaint Date
Filed
FOR OFFICE USE ONLY
Date Received: _________________________
Actions Taken: ________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________