Your Contact Information

 *

Your Contact Information

First and Last Name

Email Address

Phone Number

Street Address

City

State

Zip Code

Details of Complaint

Details of Complaint

Date of Incident

Approximate Time of Incident

Location of Incident

Name(s) or General Description of Involved Employee(s)

Describe What Happened

Witness Information: Please provide name(s) and contact information for any witnesses.

Witness Information: Please provide name(s) and contact information for any witnesses.

Would you like someone from the Leesburg Police Department to contact you about this complaint?

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Would you like someone from the Leesburg Police Department to contact you about this complaint?

Yes

No

If you would like to be contacted, please ensure you have provided your email address and/or phone number above.  Often, a supervisor will follow up with you if they have additional questions to investigate your concerns.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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