Pulaski County Missouri

Patrol Division

Jimmy Bench, Sheriff

Pulaski County Sheriff's Department

Citizens Complaint Form

Deputy's Name

Complaint's Name: Last, First MIddle

Email

Phone Number

Witness Name: Last, First Middle

Address, City, State, Zip Code

Address: City, State, Zip Code

Date and Time of the Incident:

Location of the Incident:

Details of the Complaint:

Complaint Affirmation

I do hereby affirm that the for going information is true and complete to the best of my knowledge and belief. I understand that any false, misleading, or untrue statements or writings given to any person(s) investigating this complaint may subject me to criminal and/or civil prosecution by the accused.

I further realize that it may become necessary during the investigation of this complaint, for me to meet with a member(s) of the Pulaski County Sheriff Department (PCSD), or any outside agency/investigator assigned to assist PCSD in this matter, to discuss this complaint, either in the presence or absence of the accused department member(s) at the discretion of the department. I also agree to make any evidence relating to this matter available for examination. I hereby accept the premise that if any action is initiated through a court or administrative hearing as a result of my complaint, my testimony at these hearings may be required. I hereby agree to make myself and any evidence relating to this complaint available to any such court or administrative hearing when requested to do so.

Name: First, Middle, Last

Date:

           Thank You   Sheriff Jimmy Bench