AFFIDAVIT

FORMAL CITIZEN COMPLAINT FORM

COMPLAINANT

NAME: _______________________________________ AGE: ____ DOB: ______________

ADDRESS: ______________________________________ PHONE: ___________________

BUSINESS ADDRESS: ___________________________ BUS. PHONE: _______________

I, ________________________________________________, make the following true and correct statement voluntarily, of my own free will. It is made without any threat, coercion, offer of benefit, favor, or offer of favor by any person whatsoever.

RESPONDENT

NAME OF ACCUSED (IF KNOWN): _____________________________________________

IF UNKNOWN, PROVIDE DESCRIPTION: ________________________________________

EMPLOYMENT: ______________________________________________________________

ALLEGED INCIDENT OCCURRED: ________/_____/_____ AT _____ AM PM

MONTH DAY YEAR

LOCATION OF INCIDENT: _____________________________________________________

(On the pages that follow, describe in detail the nature of the incident, giving specific details, statements, violations, locations, and/or personal injuries.)

Mail or deliver the completed packet to:

Creek County Sheriff’s Office

Sheriff Steve Toliver

P.O. Box 927

Sapulpa, OK 74067

______________________________________

Signature of Complainant

______________________________________

Date of Statement

CONTINUATION OF FORMAL CITIZEN COMPLAINT

COMPLAINANT: _____________________________________________________________

RESPONDENT: _______________________________________________________________

List specific allegation (s):

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

4. ___________________________________________________________________________

5. ___________________________________________________________________________

6. ___________________________________________________________________________

7. ___________________________________________________________________________

8. ___________________________________________________________________________

9. ___________________________________________________________________________

10. __________________________________________________________________________

IN NARRATIVE FORM, PLEASE DESCRIBE OR EXPLAIN THE ACTIONS THAT ARE ALLEGED TO HAVE BEEN COMMITTED BY THE RESPONDENT:

______________________________________________________________________________

_____________________________________________________________________________

____________________________________

Signature of Complainant

____________________________________

Date of Statement

CONTINUATION OF FORMAL CITIZEN COMPLAINT

COMPLAINANT: _____________________________________________________________

RESPONDENT: _______________________________________________________________

_____________________________________________________________________________

____________________________________

Signature of Complainant

____________________________________

Date of Statement

CONTINUATION OF FORMAL CITIZEN COMPLAINT

COMPLAINANT: _____________________________________________________________

RESPONDENT: _______________________________________________________________

_____________________________________________________________________________

____________________________________

Signature of Complainant

____________________________________

Date of Statement

CONTINUATION OF FORMAL CITIZEN COMPLAINT

COMPLAINANT: _____________________________________________________________

RESPONDENT: _______________________________________________________________

_____________________________________________________________________________

____________________________________

Signature of Complainant

____________________________________

Date of Statement

In the following paragraph, please sign your name, circle your response, and initial. Regardless of your decision concerning the polygraph (lie detector), your complaint will be investigated.

I, ________________________________________, voluntarily agree OR will not agree of my own free will to submit to a polygraph (lie detector) examination to support the truthfulness of my complaint.

I, _______________________________________________, have read (or have had read to me) the foregoing statement, consisting of ______ pages, to which I have affixed my signature, and affirm the facts contained therein are true and correct.

NOTICE OF RACIAL PROFILING:

Racial Profiling is defined as the detention, interdiction, or other disparate treatment of an individual solely on the basis of racial or ethnic status. If you believe you have been a victim of racial profiling, you may file a complaint with the State of Oklahoma Human Rights Commission or the District Attorney’s Office in the county where the incident occurred.

Witness Signature: __________________________ Print Name: _________________________

Witness Address: ________________________________City/ST: ____________ Zip: _______

Witness Home Phone: ____________________ Witness Work Phone: _____________________

Subscribed and sworn to before me, a Notary Public, in and for said County and State, this _____ day of __________________, 20_____.