Blinn College District Police Department

Complaint

BEFORE ME, the undersigned authority, on this day personally appeared

who after being duly sworn on his/her oath deposes and says:

My name is . I reside at in the City of .

My home phone number is . I am employed by .

My employer’s address is . My employer’s phone number is .

I am years of age. My date of birth is .

I have completed years of formal education. I do / I do not read, write, and understand the English language.

I have / I have not complained against an employee of the Blinn College District Police Department previously.

My complaint in this instance is against regarding an incident at on (date) at (time) .

My complaint is based on the following facts:

Subscribed and sworn before me this day of 20 .

Complaint (Continued)

Subscribed and sworn before me this day of 20 .

Complaint (Continued)

Subscribed and sworn before me this day of 20 .

Internal Affairs Statement Notification

The filing of a formal complaint against an employee of the Blinn College District Police Department by you institutes an administrative investigation which could result in disciplinary action being taken against the employee(s).

Therefore, a person who makes a false statement under oath concerning a complaint filed (as required by Section 614.022, Texas Government Code) against a law enforcement officer, with intent to deceive and with knowledge of the statement’s meaning, is guilty of Aggravated Perjury under Section 37.03 of the Texas Penal Code if he/she has knowledge of the content of the complaint, the purpose of its filing, and the official character of the investigation conducted in connection therewith, and the statement is material.

I acknowledge that I have read the above statement prior to or at the conclusion of my statement.