2. This form is used to file a complaint regarding a deputy's or other employee's conduct or the level of service provided by the Sheriff's Office.
4. 
   
6. Your Information
8. 
   
10. First Name:*
11. Middle Initial:
12. Last Name:*
14. Address:*
16. City:*
17. State:*
18. Zip:*
20. Home Phone:*
21. Work Phone:
22. Email:*
24. 
    
26. Witness 1 Information
28. 
    
30. First Name:
31. Middle Initial:
32. Last Name:
34. Address:
36. City:
37. State:
38. Zip:
40. Home Phone:
41. Work Phone:
43. 
    
45. Witness 2 Information
47. 
    
49. First Name:
50. Middle Initial:
51. Last Name:
53. Address:
55. City:
56. State:
57. Zip:
59. Home Phone:
60. Work Phone:
62. 
    
64. Incident Information
66. 
    
68. Please enter the deputy(s) / employee(s) names:
70. 
    
72. Incident Location:*
73. Date of Incident:*
74. Time of Incident:*
76. 
    
78. State your specific complaint(s) and explain the circumstances, giving the relevant facts known to you:*
80. 
    
82. Affirmation
84. 
    
86. I do hereby affirm that the foregoing information provided by me is true and complete to the best of my knowledge and belief. I understand that any false or misleading statements, accusations or allegations made by me in relation to this complaint, either orally or in writing, may subject me to civil action and/or criminal prosecution.

    I realize that to assure a thorough investigation of this matter, it may become necessary for me to meet with representatives of the Loudoun County Sheriff’s Office for the purpose of discussing this incident in detail. I further understand that if a trial board hearing or court hearing results from this investigation, my presence and testimony at such hearing may become necessary. I hereby agree to make myself available at reasonable times and places as may be necessary for such interviews and/or hearings.
88. 
    
90. By submitting this form, you are agreeing to the above statement.
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92. Submit Submit and Print

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