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2. 
4. Instructions:
   If you would like to compliment a Southampton Town Police Department employee, or file a complaint against a police employee, please write legibly and fill out this form. Personal information will not be disclosed to the public, unless required by law. You can submit this form by mailing or returning it to the Southampton Town Police Department at the address given at the top of this page.
6. I wish to file a (please check one):

   1. Compliment

   1. Complaint

   Notice: You may file a compliment or complaint anonymously. Please understand filing anonymously does not provide the opportunity to contact you for more information or advise you of our actions related to your compliment or complaint
8. Do you wish to remain anonymous?

   1. Yes

   1. No
10. First Name
11. Last Name
13. Address, City, State, Zip
15. Phone Number / Cell Phone Number
16. Reply Email
18. Are you filing this on behalf of someone else?

    1. Yes

    1. No
19. What is your relationship to you?
21. His/Her First Name
22. His/Her Last Name
23. HIs/Her Age
25. Address, City, State, Zip
27. Phone Number / Cell Phone Number
28. His Her / Reply Email (Optional)
32. Information about the incident
34. Police Officer or Employee involved
    Name or ID# of Officer or Employee
36. Narrative Section
38. Date / Time Incident
    Date / Time Incident

    Date / Time Incident
39. Location or Address of Incident
41. Witness First Name
42. Witness Last Name
43. Witness Age
45. Witness Address, City, State, Zip
47. I attest that the above information and my statement are true and correct to the best of my recollection*
    Digital Signature Submittal
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field