Form DSSP4424B "Personnel Complaint Affidavit" - Louisiana

What Is Form DSSP4424B?

This is a legal form that was released by the Louisiana State Police - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Louisiana State Police;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DSSP4424B by clicking the link below or browse more documents and templates provided by the Louisiana State Police.

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Download Form DSSP4424B "Personnel Complaint Affidavit" - Louisiana

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DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
COMPLAINANT
PERSONNEL COMPLAINT AFFIDAVIT PAGE
Fill in all blanks at the top of the page (Date & Time when affidavit is completed, and all complainant
information).
“Parish of” is the parish where the affidavit is completed.
The blank after “Before me, the undersigned authority” remains blank and will be completed by the
Trooper or Notary.
The blank after “Personally came and appeared” is the complainant’s name.
The blank after “Do hereby file an official complaint against” is the Trooper or DPS Officer’s name, if
known.
Initial the bottom right corner of each page
ALL CONTINUATION PAGES
Fill in all blanks in the complainant information portion at the top of the page (Name, Date of Birth,
Age, DL#, State).
LAST PAGE
Fill in all known information into the witness information blanks at the top of the page.
The blank after “Thus done, read and signed at” should be the city where the Affidavit is completed.
The blank after “State of Louisiana, this” should be the numerical day of the month, the blank after “day
of” should be the month, and the blank after this should be the numerical year. All information in this
section should be when the Affidavit is completed, NOT when the incident took place.
The “AFFIANT” blank is for the complainant’s signature and must be signed in the presence of the
EX-OFFICIO / NOTARY PUBLIC.
The “EX-OFFICIO/NOTARY PUBLIC” should be left blank as well as all information below this. It
will be completed by the person taking the complaint or the Notary.
TROOPER OR NOTARY
PERSONNEL COMPLAINT AFFIDAVIT PAGE
Trooper Only: Complete all information in the “Internal Use Only” box that is known. If one of the
blanks is unknown, leave it blank. After complete, submit to the Troop or Section Commander.
Your name should go into the blank after “the undersigned authority”.
LAST PAGE
Your name goes in the blank above “EX-OFFICIO / NOTARY PUBLIC” and circle the appropriate
title.
Print your name in the corresponding blank.
Put your EX-OFFICIO or NOTARY NUMBER in the corresponding blank.
Trooper Only: Your commission expires “effective until rescinded.”
Notary Only: Your commission expires on the date listed on your card.
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1
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DPSSP 4424B
Complainant’s Initials
DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
COMPLAINANT
PERSONNEL COMPLAINT AFFIDAVIT PAGE
Fill in all blanks at the top of the page (Date & Time when affidavit is completed, and all complainant
information).
“Parish of” is the parish where the affidavit is completed.
The blank after “Before me, the undersigned authority” remains blank and will be completed by the
Trooper or Notary.
The blank after “Personally came and appeared” is the complainant’s name.
The blank after “Do hereby file an official complaint against” is the Trooper or DPS Officer’s name, if
known.
Initial the bottom right corner of each page
ALL CONTINUATION PAGES
Fill in all blanks in the complainant information portion at the top of the page (Name, Date of Birth,
Age, DL#, State).
LAST PAGE
Fill in all known information into the witness information blanks at the top of the page.
The blank after “Thus done, read and signed at” should be the city where the Affidavit is completed.
The blank after “State of Louisiana, this” should be the numerical day of the month, the blank after “day
of” should be the month, and the blank after this should be the numerical year. All information in this
section should be when the Affidavit is completed, NOT when the incident took place.
The “AFFIANT” blank is for the complainant’s signature and must be signed in the presence of the
EX-OFFICIO / NOTARY PUBLIC.
The “EX-OFFICIO/NOTARY PUBLIC” should be left blank as well as all information below this. It
will be completed by the person taking the complaint or the Notary.
TROOPER OR NOTARY
PERSONNEL COMPLAINT AFFIDAVIT PAGE
Trooper Only: Complete all information in the “Internal Use Only” box that is known. If one of the
blanks is unknown, leave it blank. After complete, submit to the Troop or Section Commander.
Your name should go into the blank after “the undersigned authority”.
LAST PAGE
Your name goes in the blank above “EX-OFFICIO / NOTARY PUBLIC” and circle the appropriate
title.
Print your name in the corresponding blank.
Put your EX-OFFICIO or NOTARY NUMBER in the corresponding blank.
Trooper Only: Your commission expires “effective until rescinded.”
Notary Only: Your commission expires on the date listed on your card.
Page of 5
1
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DPSSP 4424B
Complainant’s Initials
DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
PERSONNEL COMPLAINT AFFIDAVIT
Internal Use Only
Date Written Affidavit Received: _________________________________
DATE: _______________________
IA or Non IA Case Number ______________________________________
TIME: _______________________
Assigned to: ___________________ Date Assigned: __________________
(COMPLAINANT INFORMATION)
NAME: ________________________________________________________
DATE OF BIRTH: _________________
AGE: ______
D.L #: ___________________
STATE: ____________
PHYSICAL ADDRESS: ______________________________________________________________________________
CITY: ___________________________________
STATE: _________
ZIP CODE: __________
TELEPHONE (RESIDENCE): ____________________
CELL PHONE: ____________________
STATE OF LOUISIANA
AFFIDAVIT
PARISH OF ____________________
Before me, the undersigned authority ____________________, personally came and appeared: ______________________,
who after being duly sworn, deposed as follows:
I, the undersigned, do hereby file an official complaint against ________________________________________________.
My complaint is as follows:
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DPSSP 4424B
Complainant’s Initials
DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
PERSONNEL COMPLAINT AFFIDAVIT
CONTINUATION PAGE
COMPLAINANT INFORMATION
NAME: ____________________________________________________________________________________________
DATE OF BIRTH: _________________
AGE: ______
D.L #: ___________________
STATE: _________
Continuation Page:
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DPSSP 4424B
Complainant’s Initials
DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
PERSONNEL COMPLAINT AFFIDAVIT
CONTINUATION PAGE
COMPLAINANT INFORMATION
NAME: ___________________________________________________________________________________________
DATE OF BIRTH: _________________
AGE: ______
D.L #: ___________________
STATE: _________
Continuation Page:
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DPSSP 4424B
Complainant’s Initials
DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF STATE POLICE
Witness information:
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Telephone Number(s): ________________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Telephone Number(s): ________________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Telephone Number(s): ________________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Telephone Number(s): ________________________________________________________________________________
I hereby swear or affirm that all of the information I have provided in this Affidavit is true and correct. I fully understand
that by signing this affidavit, I will be required to appear at and testify if necessary, at any administrative hearing to which I
am subpoenaed. I agree to return to testify when notified, and I realize that failing to do so may result in this complaint
being terminated.
I agree to furnish, at my own expense, any medical records or documents and witness names which the State Police Internal
Affairs investigation may request of me in regard to this complaint. I understand in order for there to be a thorough
investigation my cooperation is required; and further that if I fail to cooperate or provide the records or witness names
within ten working days that the investigation may be terminated.
I fully understand that any false statement I make to the State Police Internal Affairs investigators or designee, in regard to
this complaint may be a violation of LRS 14:133.5, Filing a False Complaint Against a Law Enforcement Officer. The
crime of filing a false complaint against a law enforcement officer is punishable by a fine of up to five hundred dollars
($500.00) or imprisonment in the Parish jail for up to six (6) months or both.
I have been advised that Louisiana State Police has a policy prohibiting retaliation for filing a complaint against an officer.
In the event I believe I have been retaliated against for filing this complaint, I understand that I may report such information
to Internal Affairs for investigation.
I certify that I have read this form and understand it in full, and that all of the information that I have given or will give to
the State Police Internal Affairs investigators or designee is true and correct to the best of my knowledge.
Thus done, read and signed at ____________________, State of Louisiana, this ______day of __________, _______.
_____________________________________________
_____________________________________________
AFFIANT
EX-OFFICIO / NOTARY PUBLIC
(circle one)
_____
_______________________________________
PRINT NAME
EX-OFFICIO or NOTARY NUMBER
_________
MY COMMISSION EXPIRES
________________
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DPSSP 4424B
Complainant’s Initials
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