Citizen's Criminal Complaint Request Form

I, the undersigned, hereby certify that I request a complaint against the following person(s) for the following actions that were committed in my presence, pursuant to section 837 of the California Penal Code.

Person(s) Involved

Please separate names using a comma between each name.

Violation(s)

Date Occurred

Time Occurred

Location Occurred

Witnesses

Please separate names using a comma between each name.

Facts upon which complaint is made (statement):

Agreement and Personal Information

I agree to appear as a witness at any trial or hearing concerning these charges. I declare under the penalty of perjury that the forgoing is true and correct. This declaration is made on this date in the City of Mt Shasta, County of Siskiyou, and State of California.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Email Address

Date of Birth

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