E-Complaint Form

Independent Police Complaints Commission

E-Complaint Form

A - Personal Details

Surname *

Other Names *

ID *

Gender *

Male Female

Date of Birth *

Age *

District *

Town/Village (Locality) *

Residential Address (Street Name) *

Email Address *

Occupation (if any)

Contact Details (Home Or Mobile)

No.1 *

No.2

B - Complaint

Complaint against (Names of Police Officers if they can be identified)

ii)

iii)

Police Station/Unit *

Date of Occurrence

Place of Occurrence *

Witnesses (if any)

(i) Witness Name 1

(i) Witness Contact Number

(i) Witness Address

(ii) Witness Name 2

(ii) Witness Contact Number

(ii) Witness Address

Injuries sustained (if any)

PF 58 issued *

Yes No

Whether services of Counsel retained *

Yes No

Relate the detailed incident in the text box below. You may write in English, French, and/or Creole *

Attach document (if any) Supported file types: PNG | JPG | JPEG | PDF

I, hereby declare that I am making this complaint in good faith and that the facts contained therein are true and correct and regarding which I assume full responsibility.

Date:

In case encountering any problem, kindly phone on 260 0513