Civilian Complaint Form English (PDF)

Please give this completed document to a Police Supervisor or send it to the Internal Affairs Unit of this 
agency at the following address or email:  Chief Marc Balestracci, Waterford Police Department, 41 Avery 
Lane, Waterford, Connecticut 06385.  Email:  mbalastracci@waterfordct.org 
Date of Incident 
Time of Incident  
Date Reported  
Time Reported 
Location of Incident 
Complainant’s Name 
Complainant’s Address (Street, City, State, ZIP) 
Complainant’s DOB 
Complainant’s Home Phone# 
Complainant’s Work Phone# 
Complainant’s Cell Phone# 
Complainant’s E-mail 
Employer 
Occupation 
Employer’s Address 
Employer’s Telephone 
Name of Person Assisting Complainant 
Address 
Telephone 
Employee Complained about (if known):  (Name or physical description, Badge #, Car #, etc.) 
Witness Information (Name, D.O.B., Address, Telephone #, etc.) 
Please provide answers to the following questions:  
 YES 
  NO  
 UNSURE 
1.
To your knowledge, was all or any part of the incident complained of video or
audio taped by anyone?
2.
Are you afraid for your safety, or that of any other person, for any reason as a
result of making this complaint?
3.
Has anyone threatened you or otherwise tried to intimidate you in an effort to
prevent you from making this complaint?
4.
Are you able to read, write and speak the English Language?
5.
If your answer to Question #4 is “No” or “Unsure”, have you been provided
with adequate language assistance to help you understand and fill out this form?
Waterford Police Department 
41 Avery Lane Waterford, Ct 06385 
CIVILIAN COMPLAINT REPORT 

 
 
 
I have read, or had read to me, the above and attached complaint and statement consisting of ____ pages.  All of the 
answers are true and accurate to my knowledge.  I understand that making a false statement  intended to mislead a 
law enforcement officer in his official function is a violation of Connecticut General Statute 53a-157b and could result  
in my arrest and being fined and/or imprisoned. 
Complainant’s Signature 
Date and Time Signed   
On this the _____ day of _______________, _________, 
the complainant whose name is subscribed above, 
personally appeared before me, the undersigned 
Officer, and acknowledged that he/she truthfully 
executed this instrument for the purposes herein 
contained.        
 Notary (For Authority See C.G.S. §§1-24, 3-94a et seq.) 
 
Print Rank/Name/ID Number: 
 
 
 
 
 
Method of Contact (Check):           Telephone              In-Person               Mail                E-Mail                 Other 
 
Signature of person receiving complaint 
Complaint Control Number 
(If you answered “Yes” to any of the above questions, please provide details below.) 
Details of the Incident:  Please provide a full description of the circumstances that prompted your complaint.  Attach 
supporting documentation, as appropriate; including letters, e-mails, photographs, video or audio tapes, etc.    
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(Attach additional pages, if necessary) 
Person Receiving the Complaint 
Rank/Name/ ID Number                                                                         Date Received                                  Time Received