San Francisco Sheriff's Department

Statement of Citizen Complaint
Against an Employee and/or Departmental Action

Date

Time

Facility/Unit

Primary Complainant

Last Name

Middle Initial

First Name

Date of Birth

Ethnicity

Sex

CDL#

Occupation

Home or Mailing Address

Work Address

Incident Information

Date of Incident

Time

Location

Were you injured?

Yes No

If yes, please describe your injuries:

When did you seek medical attention?

Where did you seek medical attention? Physician:

Name of Medical Facility:

Please read carefully and select from the options below:

I am willing to sign medical records release to assist in the investigation of my complaint.

Yes No

I have names of witnesses and will provide them to assist in the investigation.

Yes No

This complaint is against __________ of the San Francisco Sheriff's Department

a single member more than one member

Complainant's Statement:

Penal Code 148.6 - False Allegations of Police Conduct (Notice)

You have the right to make a complaint against a Deputy Sheriff for any improper peace office conduct. California law requires this agency to have a procedure to investigate citizen's complaints. You have a right to a written description of this procedure. This agency may find after investigation that there is not enough evidence to warrant action on your complaint; even if that is the case, you have the right to make the complaint and to have it investigated if you believe an officer behaved improperly. Citizen complaints and any reports or findings relating to complaints must be retained by this agency for at least five years.

San Francisco Sheriff's Department

Statement of Citizen ComplaintAgainst an Employee and/or Departmental Action

Primary Complainant

Incident Information

Please read carefully and select from the options below:

Penal Code 148.6 - False Allegations of Police Conduct (Notice)

Statement of Citizen Complaint
Against an Employee and/or Departmental Action