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2. This form is for use by members of the public who wish to make a complaint concerning an employee of the Van Buren County Sheriff's Office. This form should be filled out as completely as possible when submitted to the Van Buren County Sheriff's Office

6. Section I. About You

8. Title
   -- Select One --Ms.Mrs.Mr.Other
10. First Name
11. Middle Name
12. Last Name
14. Address
15. City
17. State
18. Zip Code
19. Email Address
21. Home Phone Number
22. Work Phone Number
23. Cell Phone
25. Preferred Method Of Contact
    -- Select One --Home PhoneWork PhoneCell PhoneEmail
26. Preferred Hours

30. Section II. About Known Witnesses

    Tell us about others who may have witnessed or taken part in the incident. If extra space is needed, list the additional witnesses or information in Section V. 

32. Name
33. Address & Phone Number
35. Name
36. Address & Phone Number
38. Name
39. Address & Phone Number

43. Section III. About Our Employees

    List all Van Buren County Sheriff's Office employees you are complaining about, and include rank and full name if known. If extra space is needed, list the additional employees or information in Section V. 

45. Employee 1
47. Employee 2
49. Employee 3

53. Section IV. About the Incident

    Be as specific as possible and provide all requested information. 

55. Date & Time
    Date & Time

    Date & Time
56. Location
58. Related Police Report Number
59. N/A or Unknown

    1. N/A
    2. Unknown
61. Sheriff's Office License Plate Number
62. N/A or Unknown

    1. N/A
    2. Unknown

66. Section V. Description of Incident

    To assist us with accurately identifying the incident, describe the incident in as much detail as possible. Use this area to list any additional individuals having knowledge of the incident who were not already disclosed. Attach additional sheets as necessary. 

68. Description
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit Submit and Print

* indicates a required field