Discrimination Compliant Form – NAACP Fort Lauderdale/Broward Branch

Police Complaint Center

Step 1 of 3

POLICE COMPLAINT CENTER

To conduct a complete and thorough investigation of your complaint, we need you to answer the following questions. Please be as specific as possible. At the NAACP’s discretion, I hereby authorize the evaluation of my allegation of brutality/misconduct, and I authorize the NAACP to file a complaint as an interested third-party with the law enforcement agency I have identified. I understand that the NAACP is not obligated to contact me regarding the investigation of this complaint. The NAACP is not responsible for the evaluation of this complaint by the law enforcement agency identified in this complaint.

Name *

First

Last

Date of Birth

Sex

Male
Female

Email Address *

Cell Phone Number *

Home Phone *

Work Phone Number

Zip Code

Next: Police Incident Information

Click Continue to provide information on your discrimination Complaint…

Please Select your complaint:

Date / Time

Date

Time

Location of the incident (Full Address):

Name of police agency involved

List the Names of the officers Involved

List any names, badge numbers, vehicle numbers and/or license plate numbers, and/or provide physical descriptions of all the officer(s) involved, including race and gender of each officer:

Did officers present any warrants as a basis for this encounter? *

Choose one

What was the reason for the stop or encounter as stated by the officer?

7. Were you handcuffed, fingerprinted, taped or photographed? *

Choose one

Did you sustain any injuries? *

Choose one

Did you receive any medical attention? *

Choose one

Were you arrested? *

Choose one

Were you issued any tickets? *

Choose one

What was the final action taken by the law enforcement officers? __

What was the final action taken by the law enforcement officers? *

Choose one

Were there witnesses who observed the incident *

Choose one

Provide full names, addresses, phone numbers, and any other identifying data.

Have you been the victim of excessive force or police misconduct in the past 12 months? *

Choose one

Have you already tried to file a complaint or grievance with the law enforcement agency? *

Choose one

Have you contacted an attorney? *

Choose one

Do you have prior criminal history? *

Choose one

Are you an NAACP member? *

Choose one

Are you willing to make a sworn statement in person? *

Choose one

Do you want NAACP representatives present when making this statement? *

Choose one

Please give a detailed accounting of what happened.

Issue Record #

NAACP Tracking #

LEO Incident #

Compliant Sunmmary

Next: Complete & Submit

Click continue to complete your discrimination Complaint information and submit your form online.

Acknowledgement & Form Submission

The NAACP is not responsible for ensuring that law enforcement officials receive this complaint form. I further understand that the NAACP will not independently investigate any allegations associated with this complaint unless agreement to do so is set forth in writing. I understand that I am solely responsible for all statements contained in my complaint. I understand that it is my sole responsibility to contact the police department identified in this complaint to ensure follow-up on my allegations and to verify receipt of the information I have provided. I hereby release the National NAACP and its units including all NAACP members from all liability associated with my allegations and complaint of misconduct/brutality. I hereby waive any claims of liability against the National NAACP and or its units for dissatisfaction with any service provided to me. Furthermore, I understand that the assistance provided to me is not intended as legal advice or legal counsel. I understand that the NAACP is not obligated to represent me unless otherwise set forth in writing. Investigation of this complaint and the allegations contained herein and the development of any criminal or civil case arising out of this matter should be managed by a private attorney retained by the complainant.
The NAACP urges the complainant to seek private legal counsel concerning all matters related to this complaint of police misconduct/brutality. I have reviewed, read, and fully understand all terms and conditions set forth in this document. I attest to this fact by signing below Person making complaints, if making this complaint on behalf of another, please state:

http://pixxelsi11.sg-host.com/membership/

Are you making this complaint on behalf of another person? *

Choose one

I, *

do hereby authorize the Fort Lauderdale Broward branch of the NAACP to investigate my complain and to take any steps necessary to resolve it. I understand that the Forth Lauderdale Branch of the NAACP does not provide legal assistance and is not acting as my attorney in this matter.

Complaintant's Signature

Print Full Name *

Date / Time

Date

Time

Witness Signature

Upload any additional supporting documantation here

Click or drag files to this area to upload. You can upload up to 3 files.

Files supported are: .pdf, .docx, .doc, .jpeg, .png, .mp4 (file size limit is 5 MB)