Civil Liberties Complaint Form

SANTA CLARA VALLEY CHAPTER

OF THE

AMERICAN CIVIL LIBERTIES UNION

CIVIL LIBERTIES COMPLAINT FORM

TODAY’S DATE: ____________________________________________________________________

YOUR NAME: ______________________________________________________________________

YOUR PHONE NUMBER(S): ___________________________________________________________

YOUR PHYSICAL ADDRESS: __________________________________________________________

YOUR E-MAIL ADDRESS: _____________________________________________________________

NAME, ADDRESS, BADGE #, AND OTHER CONTACT INFORMATION OF THE PARTIES ABOUT WHOM
YOU ARE COMPLAINING: _________________________________________________________________

______________________________________________________________________________________

HAVE YOU FILED A COMPLAINT IN THIS MATTER? ________

IF SO, PLEASE ATTACH A COPY OF THE COMPLAINT AND ANY RESPONSES TO THE COMPLAINT.

IF APPLICABLE, PLEASE PROVIDE THE REPORT #/CITATION #: _________________________________

NAME OF LAW ENFORCEMENT OFFICER INVOLVED IN THE INCIDENT, IF ANY, INVOLVED IN THE INCIDENT: ______________________________________________________________________________________

BADGE # OF LAW ENFORCEMENT OFFICER INVOLVED IN THE INCIDENT: __________________

DATE OF INCIDENT: _________________________________________________________________

TIME OF INCIDENT: ____________________________________________________________________

LOCATION OF INCIDENT: ____________________________________________________________

ARE YOU CURRENTLY REPRESENTED BY AN ATTORNEY? __________________________________

NAMES AND CONTACT INFORMATION OF ALL KNOWN WITNESSES TO THE INCIDENT:_________________

______________________________________________________________________________________

DESCRIPTION OF THE INCIDENT IN WHICH YOU ARE COMPLAINING: ____________________________

______________________________________________________________________________________

(Please add an additional page if the information does not fit on these lines )

Please note that we are not responsible for any original documents that you choose to send to us. If you already have an attorney, please have your attorney contact us directly if your attorney would like to receive our assistance. It is our policy to not represent a client who is represented by legal counsel unless such legal counsel expressly requests our assistance.

Please note that by receiving and processing this complaint, the ACLU of Santa Clara Valley is not undertaking your legal representation and is not responsible for meeting any statute of limitations restrictions in your case. Also, the ACLU of Santa Clara Valley is unable to provide you with emergency assistance or legal consultation.

I certify that I have read all of the information contained on this complaint form, and that all information I have given is accurate and complete to the best of my knowledge. I understand that by receiving and processing this complaint the ACLU of Santa Clara Valley is not undertaking my legal representation and is not responsible for ensuring that any statute of limitations restrictions are complied with in my case. I hereby expressly authorize the ACLU of Santa Clara Valley to use this information in any manner that it deems necessary.

Print and mail to:
Legal Screening Committee
ACLU Santa Clara Valley Chapter
P.O. Box 5303
San Jose, CA 95150-5303

Or

e-mail to: acluscv@hotmail.com

Other intake information: http://www.acluscv.org./intake.html

Santa Clara Valley Chapter of the ACLU of Northern California, Inc.

www.acluscv.org acluscv@hotmail.com 408-327-9357 (voicemail only) P.O. Box 5303, San Jose CA 95150

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