Criminal Complaint - Washington County Attorney

Today's date and time:

Date

Time

I hereby make the following free and voluntary sworn statement to the Washington County Attorney for use in any official proceedings including, but not limited to, the criminal justice system of the Commonwealth of Kentucky. I understand that IF sufficient evidence is provided to justify a criminal charge against the subject, I will then have the opportunity to sign a formal criminal complaint and will become a witness in the criminal proceedings against the defendant, and will be expected to testify on behalf of the Commonwealth of Kentucky. The charges cannot be dropped. I further understand that false statements are punishable by KRS 523.020 and can result in one to five years imprisonment.

Signature

Clear Signature

INFORMATION ABOUT YOU:

Name

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth (optional)

Social Security Number (Optional)

Name of Your Attorney

First

Last

Attorney Phone Number

Name of Employer

Work Phone Number

INFORMATION ABOUT THE PERSON AGAINST WHOM YOU ARE FILING COMPLAINT

Name

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Name of Employer

Work Phone Number

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

License Plate Number

Vehicle: Make & Model

Vehicle: Color

Vehicle: Year

Date of Birth

Height

Weight

Eye Color

Hair Color

Distinguishing Features

Race

Sex

Explain how you know this person:

Do you have children with this person?

Yes
No

If yes, list name(s), date of birth and address:

INFORMATION ABOUT THE INCIDENT YOU WISH TO REPORT:

Date / Time of Incident

Date

Time

What events led up to this incident?

Where were you when the incident occurred?

How far were you from the perpetrator of the crime?

When you became aware of the crime, did you call law enforcement?

Yes
No

Name of the agency/officer who responded to your call

First

Last

If you did not report the crime to police, please explain why:

Name of social worker, if social services is investigating:

First

Last

If your attorney, social services or law enforcement advised you concerning this incident, briefly describe that advice and who so advised you:

Describe the incident, telling exactly what happened:

List the names, addresses and phone numbers of all witnesses and a brief description of what each person witnessed. If there was no investigation by law enforcement, you are required to obtain written statements from each witness.

If there were no witnesses, please explain what evidence you have that is sufficient to prove your case:

Do you currently have criminal charges pending against you?

Yes
No

If so, do the charges relate to the events described in this complaint?

Yes
No

If yes, please list the name of the person who filed the complaint against you and/or the crime for which you have been charged:

Have you ever filed a complaint against this person before?

Yes
No

Describe any injuries and/or damages (attach estimates of damage, medical records and bills, photographs, and/or receipts for any repairs).

If you have been or will be reimbursed for any of these expenses by insurance or from any other source, please explain:

Why do you think this person did this to you?

In your opinion, what action from the Washington County Attorney’s Office would help in resolving this problem?