Police Commission Complaint Form

Complaint No. HPC:_______________

Date Received:_______________

HAWAI‘I COUNTY POLICE COMMISSION
Aupuni Center
101 Pauahi Street, Suite 9
Hilo, Hawai‘i 96720
Phone: 932-2950 Fax: 932-2949

COMPLAINT OF MISCONDUCT BROUGHT BY THE PUBLIC

The Police Commission investigates complaints of misconduct against officers or employees of the police department while on duty or acting under the color of authority. The complaint must be received in the commission’s office within 90 days of the incident. A request for an exception to the 90-day rule must be in writing with an explanation for the delay.

PLEASE TYPE OR PRINT

Name:_________________________ Birth Date:___/___/______ SS# Last 4 Digits:_______

Mailing Address:________________________________________ Phone:___________________

Date of Incident:___/___/______ Time:_________ Location:__________________________

Accused (Name, badge number, or description if unknown):

Name:_____________________________________________________________________________

SUMMARY OF COMPLAINT: Describe in detail the incident that led to this complaint. What is your specific complaint against each person? How could it be resolved to your satisfaction?

__________________________________________________________________________________

Fill out form HPCHEALTH for release of your medical records of injuries sustained.

Rev. 02/2011

(SIGN & NOTARIZE COMPLAINT ON PAGE 2.)

Page 1 of 2

I have prepared the foregoing Complaint of Misconduct Brought by the Public and hereby certify that, to the best of my knowledge, and under penalty of perjury, the statements herein are true. I understand that the County Charter only permits the Hawai`i County Police Commission to investigate complaints and to report its findings to the Chief of Police. In addition, I understand that the Police Commission is not permitted to interfere in the administrative affairs of the Police Department. I further understand that the rules of the Hawai`i County Police Commission, as well as Hawai`i Revised Statutes, Chapter 92F, also known as the Privacy Act, prohibit the unauthorized release of confidential records by the Police Commission, except as permitted by a court of competent jurisdiction.

	STATE OF HAWAI‘I	)SS
_____________________________ Complainant's Signature		)SS
	COUNTY OF HAWAI‘I	)SS
		__________
	Subscribed and sworn to me this

_____________________________ Parent/guardian's signature if complainant is a juvenile	___day of____________________, 20_____.
	_____________________________________________ Signature of Notary Public, State of Hawai‘i

	_____________________________________________ Printed name of Notary Public

	__________________Judicial Circuit

	My commission expires: __/__/____

Rev. 02/2011

Page 2 of 2

HAWAI‘I COUNTY POLICE COMMISSION Aupuni Center 101 Pauahi Street, Suite 9 Hilo, Hawai‘i 96720 Phone: 932-2950 Fax: 932-2949

COMPLAINT OF MISCONDUCT BROUGHT BY THE PUBLIC

HAWAI‘I COUNTY POLICE COMMISSION
Aupuni Center
101 Pauahi Street, Suite 9
Hilo, Hawai‘i 96720
Phone: 932-2950 Fax: 932-2949