Civil Rights Claim Evaluation

Report Law Enforcement Misconduct & Wrongful Arrests Below

Name

Address

Telephone

Date of Birth

Place of Birth (City/State)

Date of Arrest / Incident

Crimes Charged

Date of Dismissal

Police Agency Involved

Attorney's Fee Paid

Criminal Attorney

Bond Paid

Towing/impound Fees Paid

Prior Arrest History (Please include dates, number of days in jail, charges and police department involved)

Total amount of medical bills to date

If injured, describe injuries and names of medical providers