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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Alt Number
14. Location of Contact
16. City
17. State
18. Zip Code
20. Date and Time of Contact
    Date and Time of Contact

    Date and Time of Contact
22. Witness(es)
    Please list the name(s) of any witness(es) and include their contact information.
24. Police Staff Involved
    Please list the name(s) of Staff, or if you do not have names, a detailed description.
26. Please describe the incident, your comments or suggestions:
28. Contact with Staff

    1. Traffic Stop
    2. 911 Call
    3. Stop and Talk
    4. Investigation
    5. Arrest
    6. Citizen Assist
29. Type of Contact

    1. In the Field
    2. At the Police Station
    3. Electronically
    4. On the Phone
30. Would you like a Follow-up Contact

    1. Yes
    2. No
    3. Only if Needed
31. Contact Preference

    1. Electronically
    2. Phone Call
    3. By Appoinment
    4. By Mail
33. I certify that the information above is correct and true under penalty of perjury and false reporting RCW 9A.84.040.
    Your Signature or Type your Name
35. I am prepared to make a statement and, if applicable, appear at hearing or before a court.
    Your Initials or Type your Initials
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field