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Formal Citizen Complaint Form

The Clinton County Sheriff’s Office carefully investigates all complaints relating to deputy service and misconduct. We value your opinion and thank you for bringing the matter to our attention.

Please complete the form below in detail and provide as much information as you can; however, for anything that you do not know, please leave blank. The area of the form for your narrative description of the events should be as detailed as possible. Your written statement will need to be detailed and specific, especially when dealing with the allegations of verbal abuse, harassment, or conduct and behavior (rude, what was said, etc.)

Form Instructions

Formal Service Complaint Form

Statement Date:
Statement Time:

First Name
Last Name

I am years of age
and my date of birth is

I live at
in the City of
State of
Zip Code

Incident Date:
Incident Time:
AM or PM:

Location of Incident: (address or street and hundred block)
Number of Clinton County Sheriff’s Office staff involved:

List name(s), vehicles or license plate number, and/ or provide any physical description of officer(s).

1:
2:
3:
4:
Number of Witnesses:

Please provide the witnesses name, phone number and address

1. First Name
Last Name
Phone Number

Address
City
State
Zip Code

2. First Name
Last Name
Phone Number

Address
City
State
Zip Code

3. First Name
Last Name
Phone Number

Address
City
State
Zip Code

4. First Name
Last Name
Phone Number

Address
City
State
Zip Code

Your First Name
Your Last Name

Did you sustain any injuries? If yes, please list type of injuries and how they occurred:
Did you receive medical treatment? If yes, please provide Name, address and phone number of any doctors or hospitals that provided treatment. Additionally, we will need you to complete a Release of Medical Information for our agency.
Were you arrested? Were you issued a citation? If yes to either question, please describe the circumstance and list the citation number if applicable.
Please use the following space to describe the incident in detail including where you were, what you were doing, and how you came into contact with the officer(s) your complaint is against. Please be specific in describing your actions and what you said as well as the employee’s actions and what he/she said. Be specific as to what your complaint is:
This statement is a true and accurate account of what occurred and I understand that I could face criminal charges for knowingly making a false report. I understand that I will be informed of the results of this investigation. Check the option that applies:
I am willing to testify in any internal and/ or criminal hearing on this matter willing to testify in any internal and/ or criminal hearing on this matter.
I am not willing to testify in any internal and/ or criminal hearing on this matter willing to testify in any internal and/ or criminal hearing on this matter.
Complainant Signature
Date

State of
County of
This record was signed before me on

Notary Signature

Sheriff

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Law Center

241 Seventh Avenue North
Clinton, IA 52732
Driving Directions

Contact Information

563-242-9211
1-800-462-6530
563-243-7993 (Fax)
ccso@gapa911.us

Hours

Monday - Friday
8:00 a.m. - 4:00 p.m.
Open through the lunch hour
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