Legal Redress Police Complaint Form
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Date *
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Full Name is: *
Age at the time of the incident *
Date of Birth *
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Current Address *
Current City *
Current State *
Current Zip *
Phone Number *
Email Address *
Driver’s License/Official Identification Number *
Race *
Required
Sex *
The Officer is accused of *
Required
I HAVE BEEN INFORMED THAT UNDER TEXAS LOCAL GOVERNMENT CODE, SECTION 143.123 THAT:"AN INVESTIGATOR MAY NOT CONDUCT AN INTERROGATION OF A POLICE OFFICER BASED UPON A COMPLAINT BY A COMPLAINANT (PERSON) WHO IS NOT A PEACE OFFICER UNLESS THE COMPLAINANT (PERSON) VERIFIES THE COMPLAINT IN WRITING BEFORE A PUBLIC OFFICER WHO IS AUTHORIZED BY LAW TO TAKE STATEMENTS UNDER OATH."
Date of Incident *
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Time of Incident *
Time
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Location of Incident (address) *
Name of Policing Authority *
(i.e. Houston Police Department, Harris County Sheriff’s Constable, Bellaire Police Department, other – please indicate)
Number of Officers and/or Police Employees Involved *
List any names, badge numbers, vehicle numbers and/or license plate numbers, and/or provide physical descriptions of the officer(s) involved:
Number of witnesses who observed the incident:
Provide Witness full names, addresses, phone numbers and any other identifying data (If there are no witnesses, please write “NONE”)
Did you sustain any injuries? *
Did you sustain any injuries? *
If YES, injuries were sustained, please list the type(s) of injuries
Did you receive medical attention? If no medical attention, please check “NO”) *
If YES, medical attention, please provide the name, address, and telephone number(s) of doctor’s office and/or hospital visited, as well as the date you received treatment
Were you arrested during incident? *
If arrested, please list the charges filed and the disposition *
Were you issued any tickets? *
If ticketed, please list the citation(s) issued and the disposition
Have you retained an attorney regarding this complaint? *
If Yes, please provide the name, address and phone number of the attorney retained. *
Have you been a victim of excessive force by police on more than one occasion in the past twelve months?
Clear selection
If Yes, please list the type of police misconduct
If a Female Complainant was detained by a Male Officer, did the accusing officer call for a female officer to respond?
Clear selection
Have you filed a complaint with Internal Affairs?
Clear selection
Have you filed a grievance with any police union(s)?
Clear selection
If so, which one(s)?
Please provide any additional details of your complaint
Notice of Affirmation Your answer I, ________________________, state that the information provided above is true and accurate to the best of my knowledge. By submitting this document, I affirm that I understand and agree with it. Disclosure: 1. I have submitted this complaint to the NAACP Houston Branch (Unit 6183 of the NAACP), against the above listed police agency. 2. I understand that the NAACP Houston Branch is a private, non-profit, voluntary organization, and it is not a government agency. Filing a complaint with the NAACP Houston Branch is not the same as filing a complaint with an administrative agency or filing a suit in a complaint with an administrative agency or filing a suit with a court of law. Whatever rights I have to file a complaint with an administrative agency or to file a civil lawsuit are completely unaffected by whether I have filed with the NAACP Houston Branch. 3. The deadline by which I must file my complaint or lawsuit is governed by the policing agency. I understand that if I do not file my complaint or lawsuit prior to the deadline, I may forfeit my right to a recovery from any harm from the respondent. 4. In seeking assistance from the NAACP Houston Branch, I understand that the NAACP Houston Branch may refer me to a private attorney, I am not required to retain him/her, and he/she is not required to offer legal representation to me. I understand that such representation as he/she might offer me may not be without charge; but will be on whatever terms he/she and I agree upon. I understand that he/she does not represent the NAACP Houston Branch, nor is he/she employed or paid by the NAACP Houston Branch.
Full Name *
Date *
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Time *
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