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2. Nature of Feedback*
3. Date and Time Received
   Date and Time Received

   Date and Time Received
5. Which Officer is this regarding?
7. Location of Incident*
8. Date and Time
   Date and Time

   Date and Time
10. Please specify your Feedback*
12. Your Contact Information: If you wish to be followed up with, you must complete these fields.
14. First Name
15. Last Name
17. Sex
19. Address
21. City
22. State
23. Zip Code
25. Address 2 (if applicable)
27. Phone Number
28. Business Phone Number
30. Email Address
32. Witness Information
34. First Name
35. Last Name
37. Address
39. City
40. State
41. Zip Code
43. **Read before signing** a person is guilty of a class b misdemeanor if he makes a written false statement (uca 76-8-504) or knowingly givesfalse information to any law enforcement officer (uca 76-8-506.) I certify that the information contained in this complaint is true and correct to the best of my knowledge.
45. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
49. Assigned to:
50. Date Supervisor Notified
    Date Supervisor Notified
51. Date Employee Notified
    Date Employee Notified
53. Received by Division:
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55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field