Free Memorandum in Support of Motion - District Court of Connecticut - Connecticut

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_ , Case 3:03-cv-O1 O1 O-J BA Document 82-4 Filed O3/O2/2005 Page I · · I I I I ,
I 5 I ‘, _ · _ Outnzen Complaint Fog ) sf o . I Ig 3 o»a ;i.I_f;g§Q_ij;§‘_F I
I TO BE COMPLETED BY THE PERSON MAKING THE COMPLAINT I
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DATE OF COMPLAINT: 2 *45 *0 4 TIIME OF COMPLAINT: I
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I NAME: sex: Az mm: ¤»= BIRTH; Z. é -.5*0 I
ADDRESS: 2 (,;*2 HQOZQ fig 5,271C 7-I PHONE NUMBERS:.._,5 ··{ 2 { I 1
WIT SSES ( NAMEIA DRESS SEX AG PHO I I
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OFFICERS INVOLVED: NAME BADGE NO. SEX RACE CAR NUMBER I
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DATE AND TIME OF INCIDENT: Z¥-gé ···0[ Egg- QQQO gg; LOCATION OFNINCIDENT: . _Q
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WERE YOU ARRESTED?: ( _ )YES ( ;/ )NO WERE YOU INJURED?:( 4/ )YES ( )NO I
DESCRIPTION OF INJURIES: J/fe if ‘-
DID YOU RECEIVE MEDICAL TREATMENT? ( )YES ( )NO IF YES, PLEASE INDICATE WHERE
AND BYWHOM: &P7`"`gf§IQLgg6· @#72 cx; bf. [gg [@6*0 Q S ·
DESCRIPTION OF INCIDENT: (USE THE REVERSE SIDE OF THIS FORM IF MORE SPACE IS NEEDED: Q
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I AM A ARE OF THE OBLIGATION OF AN OATH AND OF THE FACTS HAT THE KNOWINGLY GIVING OF
EITHER A FALSE STATEMENT OR FALSE INFORMATION IS UNLAWFUL AND PUNISHABLE BY LAW UNDER
SECTIONS 53A·-155 ANDIOR 53A·157 OF THE CONNECTICUT GENERAL STATUTES.
IF YOU FEEL THAT YOU NEED AID IN COMPLETING THIS FORM., YOU MAY CONTACT ANY AGENCY
INCLUDING THE NAACP AT 377-4875, THE SPANISH AMERICAN DEVELOPMENT AGENCY (SADA) AT 333-5193, I
OR THE PUERTO RICAN COALITION AT 368-6781 . _ ___ I
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DATE: ?'"/y TO! SIGNATURES ZZ;/' · I
OEFICEB INITIAL BELOW SUBSCRIBED AND SWORN TO BEFORE ME ON · I
COPY OF CC-1 TO CITIZEN: THIS [E 9*6* DAY OF ’I‘9;7‘2?/
FILE CARD COMPLETED:/ `
FILE NUMBER; 0/09 /'€’» 0
· SIG ATIJRE OF INDI DUAL ING OATH
1* Q ` I
OIA: DATE COMPLAINT RECEIVED: 9 CASE NUMBER ASSIGNED:
ENCLOSURE A
FORM CC-1
REVISED: 1071997
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