CIVILIAN COMPLAINT FORM English Rev 2026

Waterford Police Department 
CIVILIAN COMPLAINT REPORT 
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: police.chief@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 Cell Phone# 
 
Complainant’s E-mail 
 
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? 
 
 
 
 
 
 
 
 

 
 
 
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 the best of my knowledge, information, and belief.  
Complainant’s Signature 
Date and Time Signed   
 
 
 
 
 
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