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Complaint No. HCFC: <br />HAWAI`I COUNTY FIRE COMMISSION <br />Aupuni Center, 101 Pauahi Street, Suite 9, Hilo, Hawaii 96720 <br />Phone: (808) 932-2950 Fax: (808) 932-2949 <br />Date Received: <br />COMPLAINT OF MISCONDUCT BROUGHT BY THE PUBLIC <br />Pursuant to Fire Commission Rule 8(A), a complaint against the conduct of the department or any of its <br />members or employees while on duty or acting under the color of authority shall be in writing, signed <br />and dated by the complaint under oath before a Notary Public. This notarized complaint must be received <br />by the Commission's office not more than 90 days from the date of the incident. A request for consideration <br />for an exception to this rule must be in writing with an explanation for the delay. A complaint form or letter <br />signed, dated, and notarized by the complainant's immediate family shall be accepted as a complaint if the <br />victim is deceased. <br />PLEASE TYPE OR PRINT <br />1►/_1iyiI=1 <br />Mailing Address: <br />Date of Incident: <br />Birth Date: SS# last 4 digits: <br />Time: Location: <br />ACCUSED: (Name or description if unknown <br />Name: <br />Name: <br />Phone: <br />SUMMARY OF COMPLAINT. List the complaint classification # as listed on the back of this form, then <br />summarize the incident of misconduct as it pertains to the classification #. <br />Name and address of physician seen for injuries: <br />(Fill out HCFCFORM-2) <br />I would like to have my complaint reviewed in a meeting open closed to the public. <br />HCFCFORM-1 Rev. 7-18-22 Page 1 (Turn page over to notarize complaint.) <br />Hawai `i County is an Equal Opportunity Provider and Employer <br />