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2. First Name
3. Last Name
5. Address1
7. Phone Number
9. City
10. State
11. Zip
13. Business Name
15. Address1
17. Address2
19. City
20. State
21. Zip
23. Phone Number
24. Email Address
26. Witness(s)
27. Last Name
29. Address1
31. Phone #
33. City
34. State
35. Zip
37. Incident
39. Address1
41. Address2
43. City
44. State
45. Zip
47. Date/ Time
    Date/ Time

    Date/ Time
48. Officer Name (if known)
49. Officer description (If unknown name)
51. Details of complaint (To be completed by complainant)
53. Name of person Assisting
54. Reason for Assisting
56. Affirmation
    I ______________________________, do hereby affirm that the foregoing information provided by me is true and complete to the best of my knowledge and belief. I understand that any false, misleading or untrue statements, accusations or allegations, herein, made by me, either orally or in writing to any person(s) investigating this complaint may subject me to civil and/pr criminal prosecution for filing a false report under F.S 316.067, F.S 817.49, or F.S 837.06 I realize that it may become necessary during the investigation of this complaint, for me to meet with a member(s) of the Cocoa Police Department to discuss this complaint, either in the presence or absence of the accused Department member(s) as the discretion of the Department. I hereby accept the premise that if any action is initiated through a court administrative hearing, as the result of my complaint, my testimony before these hearings may be required. I hereby agree to make myself available for the aforementioned court or administrative hearings when so requested to do so.
58. Signature
    I understand that this constitutes a legal signature and confirms that I agree to the above terms.
59. Date
61. State of _________________
63. County of _______________
65. Sworn to (or affirmed) and subscribed before me this ____ day of ___________, 20____, by: ______________________________ has produced ________________________.
67. Notary Public Signature ____________________________
69. Name of Notary (typed, printed or stamped)/LEO in performance of lawful duties _______________________________
71. For Departmental Use Only--TO BE COMPLETED BY RECEIVING OFFICER
    For Departmental Use Only (To be completed by the receiving officer) Receiving Officer Name: _____________________________________ Date: ____________________________ Time: _________________AM/PM Receiving Officer’s Observations of the Complainant: Complainant Furnished Copy of Complaint ? Yes / No Copy Furnished By: ______________________________________________ Date: ______________________________Time: ___________ AM/PM Related Case # (s) - ___________________________________________ _____________________________________ ______________________________ Signature of Receiving Officer Printed Name of Receiving Officer Administrative Use Only Reviewed By: ____________________________________Date: ________________________ Assigned To: ____________________________________Date: ________________________ CC / IA Received By: _____________________________________ Date: _________
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72. Print Only

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