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.

Your Information

First Name:*

Middle Initial:

Last Name:*

Address:*

City:*

State:*

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Zip:*

Home Phone:*

Work Phone:

Email:*

Witness 1 Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip:

Home Phone:

Work Phone:

Witness 2 Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip:

Home Phone:

Work Phone:

Incident Information

Please enter the deputy(s) / employee(s) names:

Incident Location:*

Date of Incident:*

Time of Incident:*

State your specific complaint(s) and explain the circumstances, giving the relevant facts known to you:*

Affirmation

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.

By submitting this form, you are agreeing to the above statement.