2. 
3. Kinston Department of Fire and Rescue
   P. O. Drawer 339, 401 E Vernon Avenue Kinston, North Carolina 28502 Office Phone: 252-939-3164 Fax Phone : 252-939-3157
5. Citizen Complaint Form
7. Complainant's Information
9. Name of Complainant:*
10. Middle Name:
11. Last Name:*
13. Date of Birth:*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
14. Day:*
    -- Select One --01020304050607080910111213141516171819202122232425262728293031
15. Year:*
    -- Select One --19501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050
17. Age:*
    -- Select One --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100
18. Gender:*
    -- Select One --MaleFemale
19. Race:*

    1. Black
    2. White
    3. Native American
    4. Asian
    5. Middle Eastern
    6. Hispanic
    7. Latino
    8. Pacific Islanders
21. Address:*
23. City:*
24. State:*
25. Zip Code*
27. Contact Phone Number:*
28. Email Address:*
30. Do you wish to remain anonymous during the preliminary investigation?*
    -- Select One --YesNo
32. Note: Selecting Yes will not make any difference in the preliminary investigation and the preliminary investigation will proceed in a timely, appropriate, and unbiased manner. If the reported complaint is found to be a criminal act, Anonymity only is for the preliminary investigation into the accusation. By constitutional law under the 6th Amendment the Accused has the right to face the Accuser if the proceedings find the accused accountable for their actions. If the reported complaint is found to be a civil matter, the Anonymity can continue throughout the process.
34. Nature of the Complaint
36. Offense Date:*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
37. Day:*
    -- Select One --01020304050607080910111213141516171819202122232425262728293031
38. Year:*
    -- Select One --2016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046
40. Time of Offense (Approximate if applicable):*
41. Location of the Offense (Approximate Address if applicable):*
43. City:*
44. State:*
45. Zip Code (If known):
47. Complaint Against:*

    1. Personnel

    1. Fire Company

    1. Shift

    1. Department
49. If Personnel please fill this section
51. Name of Accused (If known):
    -- Select One --D. N. CrawfordE. L. DavisB. K. RoddyW. J. BarssS. HarperA. L. ManessS. MartinW. S. JusticeR. E. CulbrethL. G. JenkinsT. E. GayB. HugginsN. E. HobbsM. J. ScrufariC. A. JacksonR. A. CannonS. M. SullivanT. L. SwinsonD. B. RobersonS. M. SpruillM. T. SpencerS. R. JonesJ. L. CravenT. J. HowardJ. H. LancasterD. L. StringfieldD. B. ParkerJ. C. PearsonJ. N. LeeD. G. DavisD. M. YoungS. R. TyndallT. D. MooringL. A. WilliamsB. A. GillisT. G. FoylesJ. B. ManningB. H. HarperJ. M. WeberC. I. ReeseR. S. FritterH. N. BarrowJ. W. StallingsS. B. NimmoC. L. PipkinA. J. HardyC. L. BooneR. B. ParkL. WileyT. McNair
53. Rank of Accused (If known):
    -- Select One --Fire Control SpecialistFire Control Specialist IFire Control Specialist IIMaster Fire Control SpecialistCaptainCommanderAdministration AssistantChief
55. If Fire Company please fill this section
57. Fire Company (If known) (A Fire Company consists personnel within a vehicle and can be 1 person to 4 people):
    -- Select One --Battalion 1 (B1) (License Plate #: ) (Unit #: 653)Ladder 18 (18) (License Plate #: 71480-T) (Unit #: 610)Engine 11 (11) (License Plate #: 71527-T) (Unit #: 621)Engine 22 (22) (License Plate #: 71528-T) (Unit #: 622)Engine 33 (33) (License Plate #: 71854-T) (Unit #: 603)Ladder 15 (15) (License Plate #: 13091-R) (Unit #: 613)Engine 12 (12) (License Plate #: 71433-T) (Unit #: 650)Engine 23 (23) (License Plate #: 71434-T) (Unit #: 651)Engine 34 (34) (License Plate #: 71427-T) (Unit #: 614)White in color Ford Explorer (License Plate #: 83554-V) (Unit #: 620)White in color Ford Expedition (License Plate #: 71891-T) (Unit #: 611)Tan in color Ford Crown Victoria (License Plate #: 71559-T) (Unit #: 120)Red in color Ford F350 Utility Truck (License Plate #: 71461-T) (Unit #: 606)White in color Ford F250 Truck (License Plate #: 59748-V) (Unit #: 615)White in color Dodge Ram Truck (License Plate #: 71484-T) (Unit #: 609)
59. If Shift please fill this section
61. Shift (If known) (A Shift constitutes at least 1 or more Fire Companies during a scheduled workday):
    -- Select One --A ShiftB ShiftC ShiftAdministration
63. Is the Offense Criminal in nature or Civil in nature?*

    1. Criminal

    1. Civil
65. Explanation:
67. Definition of Criminal in nature: Violations of the City, State, and Federal Laws.
69. Definition of Civil in nature: Violations against a person not fitting under law, but offensive and violating personal rights of privilege such as; using vulgar language in public, being rude, being belligerent, being disrespectful to person or property, disputes of damage/owing money for services performed, breech of contractual situations, etc...
71. Explain the Offense in Detail (Include names, dates, times and pertinent information to the offense)
73. Offense Description:*
75. Was there a witness(es) to the Offense?*
    -- Select One --YesNoUnknown
77. If Yes please provide Witness Information
79. Witness 1's Name:
80. Middle Name (if known):
81. Last Name:
83. Address:
85. City:
86. State:
87. Zip Code:
89. Contact Phone Number:
90. Email Address:
92. Does Witness wish to remain Anonymous?
    -- Select One --YesNo
94. Note: Selecting Yes will not make any difference in the preliminary investigation and the preliminary investigation will proceed in a timely, appropriate, and unbiased manner. If the reported complaint is found to be a criminal act, Anonymity only is for the preliminary investigation into the accusation. By constitutional law under the 6th Amendment the Accused has the right to face the Accuser if the proceedings find the accused accountable for their actions. If the reported complaint is found to be a civil matter, the Anonymity can continue throughout the process.
96. Witness 2's Name:
97. Middle Name (if known):
98. Last Name:
100. Address:
102. City:
103. State:
104. Zip Code:
106. Contact Phone Number:
107. Email Address:
109. Does the Witness wish to remain Anonymous?
     -- Select One --YesNo
111. Note: Selecting Yes will not make any difference in the preliminary investigation and the preliminary investigation will proceed in a timely, appropriate, and unbiased manner. If the reported complaint is found to be a criminal act, Anonymity only is for the preliminary investigation into the accusation. By constitutional law under the 6th Amendment the Accused has the right to face the Accuser if the proceedings find the accused accountable for their actions. If the reported complaint is found to be a civil matter, the Anonymity can continue throughout the process.
113. Witness 3's Name:
114. Middle Name (if known):
115. Last Name:
117. Address:
119. City:
120. State:
121. Zip Code:
123. Contact Phone Number:
124. Email Address:
126. Does Witness wish to remain Anonymous?
     -- Select One --YesNo
128. Note: Selecting Yes will not make any difference in the preliminary investigation and the preliminary investigation will proceed in a timely, appropriate, and unbiased manner. If the reported complaint is found to be a criminal act, Anonymity only is for the preliminary investigation into the accusation. By constitutional law under the 6th Amendment the Accused has the right to face the Accuser if the proceedings find the accused accountable for their actions. If the reported complaint is found to be a civil matter, the Anonymity can continue throughout the process.
130. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
132. Electronic Signature*
134. Date and Time Complaint Signed:*
     Date and Time Complaint Signed:

     Date and Time Complaint Signed:
     All of the above information is correct, accurate, true to the best of my knowledge, and electronically signed by me at this date and time.
136. 
     
Leave This Blank:


138. 1. Receive an email copy of this form.
139. Email address

     This field is not part of the form submission.

140. Submit Submit and Print

* indicates a required field