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1575 MASSACHUSETTS AVENUE • LEXINGTON, MASSACHUSETTS 02420 <br />781-862-1212/fax 781-863-1291 <br /> IA Form - 2 Page |1 <br /> LEXINGTON POLICE DEPARTMENT <br /> COMPLAINT QUESTIONNAIRE <br /> <br />Person with Complaint: __________________________________ You’re Name, if Different: _________________________________________ <br /> <br />Address: ____________________________________________________ Address: _______________________________________________ <br /> <br /> _______________________________________________________ _____________________________________________ <br /> <br />Phone #: _______________________________________________________ Phone #: ____________________________________________ <br /> <br />NATURE OF COMPLAINT: Describe in your own words everything you consider necessary for this matter to be completely <br />investigated. Please include the name(s) of any Department employee involved in your complaint. Use the backside of this sheet if <br />necessary: <br /> <br />________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />WITNESSES: Please provide names, addresses and phone numbers if available. <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />____________________________________________________________________________________________________________________ <br /> <br />WILLINGNESS TO TESTIFY: In most cases, disciplinary hearings are not required. In the event that my oral testimony is needed, I am: <br /> <br />(Check one) Willing to testify at a hearing: YES NO / Unwilling to testify at a hearing: YES NO <br /> <br />AFFIRMATION: To the best of my knowledge, the above statements are true and accurate. I understand that any false, misleading or <br />untrue statements, accusations or allegations, herein made by me, either orally or in writing, to any person(s) investigating this complaint, <br />may subject me to civil and/or criminal prosecution. Including this page, there are ________ page(s) to this questionnaire. <br /> <br /> <br />Complainant's Signature: _________________________________________________Date: ____________________ Time____________ <br /> <br />Signature of Receiving Officer: ____________________________________________Date: ____________________ Time: ____________ <br /> <br />