The race/ethnicity of the officer(s)
Provide the name and address of the Police Department.
This officer(s) is being accused of? (check all that apply)
If other please explain below.
If other give who you are.
Your Full Name
Your Phone Number
Your Complete Mailing Address
Please include your city and zip code.
What is your race: (please check those that apply)
If other please provide your race below.
What was the exact date and time of the incident?
Where was the location of the incident?
If victim was driving give the make and model of the vehicle.
If other or suspicious behavior what reason did the officer(s) give?
Were you read your Miranda rights?
If arrested what was the basis for the arrest?
If other what was the reason for the arrest?
Did the police have a warrant?
Were you subjected to a search?
If yes what was the basis?
Did the police find any evidence of criminal activity?
If yes what was that evidence?
If you refused a search, what action did the police take?
If detained, what were you detained for?
Were you injured as a result of this incident?
If yes, give a detailed statement about the injuries you received.
Were there any witnesses to the incident?
If yes give the name and contact information for these individuals.
Have you contacted an attorney about this complaint?
If yes give the name and address and phone number of your attorney.
Have you filed a complaint with the Police Department?
If yes, what response have you gotten to date?
NAACP (“NAACP”). I affirm that I have transcribed the above information and it is true and accurate to the best of my knowledge. By signing below, I acknowledge the following: The NAACP has not agreed to represent me in this matter. This complaint is submitted solely [for consideration of my claims by the NAACP Unit. I understand that the NAACP is a private, nonprofit, voluntary organization, not a government agency.Whatever rights I have to file a complaint with an administrative agency or file a civil lawsuit are completely unaffected by whether or not I have filed this my complaint with the NAACP. I understand the NAACP is not a law firm and cannot provide me with legal representation. Although some of its members, volunteers and staff are lawyers, they represent the NAACP and not me personally. I understand that if the NAACP refers me to a private attorney, I am not required to retain him / her and she / he is not required to offer legal representation to me. The NAACP in no way guarantees or vouches for the competency, professionalism or fitness of the lawyers whose names may be provided me for assistance regarding this complaint. I have authorized the NAACP to investigate my complaint and, if I have retainer an attorney, I authorize them to speak with my attorney concerning this complaint. I will provide the NAACP copies (not originals)of whatever documents I have to support the complaint. I requested in writing that some of the material be held in confidence, the NAACP will hold it in confidence; otherwise the NAACP may share it with the Respondent or with state and / or federal anti- discrimination agencies. During the investigation of my complaint by the NAACP, I will continue to notify the Unit of my other legal or administrative action I take concerning the complaint and underlying facts. I release and hold harmless the NAACP, its officers, directors, employees or agents, fi'om and all liability claims, demands, and causes of action, of whatever nature, either in law or equity, which I have hereafter have against the NAACP, upon or by reason of the NAACP’s handling of my complaint of discrimination or its declination to handle such complaint. I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.