Citizen Response Form

Florence Police Department

The Florence Police Department strives to maintain a professional image and treat citizens fairly. Every citizen shall have opportunity to provide feedback regarding the conduct of any Florence Police Department employee. This form allows you to either compliment an employee or file a complaint against an employee.

After completing this form you may submit it electronically, deliver it to the police department in person, or print it then fax or mail it.

Mailing address:

Florence Police Department Internal Affairs
702 S. Seminary St. Florence, AL 35630

Phone Number: (256) 768-2728
Email: citizenresponse@florenceal.org

COMPLETING THIS FORM:

In order for the Police Department to best follow up on your feedback, you will need to complete all sections of this form. If you have any questions, you can call 256-768-2728 to request assistance. You may also request a supervisor to assist you in completing this form if you prefer.

Florence Police Department
Citizen Response Form

Today’s Date:

(Complaint) or (Compliment/Commendation) type

Complaint
Compliment/Commendation

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Full Name: *

Date of Birth:

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Street Address:

ZIP:

State:

City:

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Phone Number:

Date of Incident:

Email Address:

Time of Occurrence:

Location of Incident:

List names, badge numbers, description of officers or vehicle numbers involved:

(List name, badge number, description of officer or vehicle number),....,

List of Witnesses Involved. Provide Full Name, Addresses, Phone Numbers. Or write “NONE”

Were you arrested? Please provide details of arresting officer and charges below:

Were you injured? Please describe your injuries below. Include the name of the medical doctor and medical institution who treated you.

Were you issued a citation? If yes, please provide the details below:

Would you like to commend or compliment an officer? Please include all the details below:

Please provide additional narrative in specific detail below:

What follow up action do you think is appropriate for this officer(s)?

Florence Police Department
Citizen Response Form
I do hereby affirm foregoing information is true & complete to the best of my knowledge & belief. I understand that it is a violation of Alabama law (13A-11-11) to willfully make a false report.

Complainant’s name or Signature: *

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Date: *

Welcome to Florence, Alabama

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Welcome to Florence, Alabama

Florence Police Department

Citizen Response Form

Mailing address:

Florence Police Department
Citizen Response Form

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