Indicates required field Complainant InformationName: Mailing AddressAddressAddress 2City/TownState- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingZIP CodeEmail:Phone NumberPhone Type:- None -Standard voice telephoneVideophone [VP]Text-telephone device [TTD]phone textWhat are these options?Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option 'Voice' is a standard audible telephone.Race/Ethnicity:WhiteBlack or African AmericanHispanic or Latino AmericanIndian or Alaska Native AsianNative Hawaiian or Other Pacific IslanderUnknownOther Race:Gender:MaleFemaleOther Gender:Date of IncidentMonthMMJanFebMarAprMayJuneJulyAugSepOctNovDecDayDD01020304050607080910111213141516171819202122232425262728293031YearTime Of Incident (Ex. 02:00pm):USCP Employee InformationName(s)- If name is not known, enter "unknown":Include rank, badge and assignment for each employee, if known. Enter each employee on a separate line.Witness Information (If Applicable)Name:Include address and phone number for each witness, if known. Enter each employee on a separate line.Upload Additional Information:Additional Info:One file only.2 MB limit.Allowed types: jpg jpeg png pdf doc docx. Signature:Typing your name and electronically sending this form constitutes your electronic signature and certifies that to the best of your knowledge the statements made herein are true, and you acknowledge that the making of false statements is punishable by criminal penalties. CAPTCHA: enabled to secure this form. If you are having difficulty using Captcha's visual option, please visit Accessibility page for more assistance.