Complaint No.  HPC                                                                                             Date Received: 

HAWAI`I COUNTY POLICE COMMISSION
The Hilo Lagoon Centre
101 Aupuni Street, Suite 313, Hilo, Hawai`i  96720
Phone: 961-8412    Fax: 961-8563
 

COMPLAINT OF MISCONDUCT BROUGHT BY THE PUBLIC

The Police Commission investigates complaints of misconduct against officers or employees of the police department while on duty or acting under the color of authority.  The complaint must be received in the commission’s office within 60 days of the incident.  A request for an exception to the 60-day rule must be in writing with an explanation for the delay.

PLEASE TYPE OR PRINT 

NAME:___________________________________________  Birth Date:_______________  SS# last 4 digits:________

   Mailing Address:_____________________________________________________  Phone:______________________

   Date of Incident:_______________________  Time:____________  Location:_________________________________ 

ACCUSED: (Name, badge number, or description if unknown.)

   Name:_______________________________________________________________________________________

   Name:_______________________________________________________________________________________

   Name:_______________________________________________________________________________________ 

SUMMARY OF COMPLAINT:  Describe in detail the incident that led to this complaint.  What is your specific complaint against each person?  How could it be resolved to your satisfaction? 

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Fill out form HPCHEALTH for release of your medical records of injuries sustained. 

Rev. 5/19/09                                                               (TURN PAGE OVER TO SIGN & NOTARIZE COMPLAINT.)

I have prepared the foregoing Complaint of Misconduct Brought by the Public and hereby certify that, to the best of my knowledge, and under penalty of perjury, the statements herein are true.  I understand that the County Charter only permits the Hawai`i County Police Commission to investigate complaints and to report its findings to the Chief of Police.  In addition, I understand that the Police Commission is not permitted to interfere in the administrative affairs of the Police Department.  I further understand that the rules of the Hawai`i County Police Commission, as well as Hawai`i Revised Statutes, Chapter 92F, also known as the Privacy Act, prohibit the unauthorized release of confidential records by the Police Commission, except as permitted by a court of competent jurisdiction.

                                                                        STATE OF HAWAI`I            )SS

______________________________                                                      )SS

Complainant’s signature                                COUNTY OF HAWAI`I         )SS

                                                                        Subscribed and sworn to me this

______________________________            ______day of ________________, 20____.

Parent or guardian’s signature if
complainant is a juvenile

                                                                        __________________________________

                                                                        Signature of Notary Public, State of Hawai`i

                                                                        __________________________________

                                                                        Printed name of Notary Public             

                                                                        ________________ Judicial Circuit

                                                                        My commission expires: ______________