STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

Citizen Complaint Against Peace Officer Form
DFPI–ENF 53 (Rev. 11-20)

CITIZEN COMPLAINT AGAINST PEACE OFFICERS
Please Read the Information Collection, Use and Access notice on page 2(916) 322-6067/ (866) 275-2677 Toll Free – CA Only
TTY/TDD (800) 735-2922 (California Relay Service)
For TTY/TDD Outside California contact your state’s relay
service number at http://www.fcc.gov/dro/trsphonebk.html
DFPI Web Site: http://www.dfpi.ca.gov

Mail form to:
Deputy Commissioner of Enforcement Division
2101 Arena Blvd
Sacramento, CA 95834
Email form to:
DFPIPeaceOfficerComplaint@dfpi.ca.gov

SECTION 1 - YOUR CONTACT INFORMATION (To receive a response in writing, you must provide your mailing address)
First Name:MI:Last Name:

Address:
City:

State:

Home Phone:

Zip Code:

Work Phone:
Email:SECTION 2 – WITNESSES AND VICTIM (if different from reporting party)

First Name:MI:Last Name:

Address:
City:

State:

Home Phone:

Zip Code:

Work Phone:
Email:SECTION 3 – PEACE OFFICER INFORMATION

Employee's Name:
Employee’s Office Location if known:
City:

State:

Zip Code:

Employee's Phone:
SECTION 4 - YOUR STATEMENT OF COMPLAINT
Provide specific information about the alleged misconduct. If more space is needed, attach additional pages. Total # of Pages
Attached:

Do Not Send Original Documents.

SECTION 5 – RACIAL OR IDENTITY PROFILING
Provideinformation
about
If moretargeted
space is needed,
Total # Pages
Is yourspecificcomplaint
based
onthe
thealleged
beliefmisconduct.
that you werebased on race, color, ethnicity, national origin, gender,age,
Attached:
attach additional pages. . Do Not Send Original Documents.

religion, gender identity or expression, sexual orientation, or mental or physical disability: Yes
If Yes, please check all that apply:

NoRace ☐ Color ☐ Ethnicity ☐ National Origin ☐ Gender ☐ Age ☐ Religion ☐ Gender Identity or Expression ☐Sexual Orientation ☐ Mental Disability ☐ Physical Disability ☐ Other (please explain) ☐[If you need more space and are using this fillable form, create a document (e.g. MS Word or WordPerfect) to print and attach.]
Signature:

Date:

STATE OF CALIFORNIA –DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

Citizen Complaint Against Peace Officer Form

DFPI–ENF 53 (Rev. 11-20) Page 2 of 3

CITIZEN COMPLAINT AGAINST PEACE OFFICER FORM
Information Collection, Use and Access
Notice Required Under State Law
The following notice is required by state law under the Information Practices Act of 1977 (California Civil
Code Section 1798.17).
All information you provide regarding the performance of this Department is voluntary and optional.
However, if you choose not to include all or any part of the information requested, the Department may beunable to fully investigate or respond to your comment or complaint.
All investigations are conducted objectively, with a goal of maintaining public confidence and departmentalintegrity. After completion of the investigation, complaints are directed through the chain of command for an
impartial review. After final approval, the citizen is provided with a closing written response. Complaints
may not always be resolved to a citizen’s satisfaction.
We may share your personal information, as needed, with licensed business entities or individuals tofacilitate resolution of your comment or complaint. We may also share your information with othergovernment agencies or self-regulatory organizations.
The Commissioner is responsible for the performance of all duties, the exercise of all powers andjurisdiction, and the assumption and discharge of all responsibilities vested by law in the Department. The
Commissioner has and may exercise all the powers necessary or convenient for the administration andenforcements of, among other laws, the laws described in Financial Code Section 300. The Commissioner
may issue such rules and regulations consistent with law as he or she may deem necessary or advisable inexecuting the powers, duties, and responsibilities of the Department.
You have a right to see your personal information. The official responsible for maintaining information
gathered by the Department of Financial Protection and Innovation is:
DFPI Privacy Officer
Department of Financial Protection and Innovation
2101 Arena Blvd
Sacramento, CA 95834

STATE OF CALIFORNIA –DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

Citizen Complaint Against Peace Officer Form

DFPI–ENF 53 (Rev. 11-20) Page 3 of 3

DFPI’s Privacy Notice on Collection
DFPI Collects and Uses Personal Information: The DFPI collects the information requested on thisform as authorized by Penal Code sections 832.5 and 13012. The DFPI uses this information to conduct
an investigation of your Citizen’s Complaint. Use of the personal Information DFPI collects is subject tolimitations contained in the Information Practices Act of 1977 and other applicable state and federal laws.
Providing Personal Information Is Mandatory: When providing information or documents, please do notinclude unrequested personal information such as a Social Security number, driver’s license number, orfinancial information.
DFPI May Disclose Your Personal Information: We may share your personal information with Stateand Federal Regulators, and law enforcement agencies. Your personal information may also bedisclosed:• In response to a Public Records Act request, as allowed by the Information Practices Act.
• To another governmental agency as required by state or federal law.
• In response to a court order or administrative order, a subpoena or a search warrant.
Your Access to Your Personal Information: You may review the records maintained by DFPI that
contain your personal information. To request access, contact: DFPI Privacy Officer, 2101 ArenaBlvd, Sacramento, CA 95834.

Contact Information: For questions about a written complaint that you submitted to the DFPI,
please specify the specific record that you are seeking. You may mail your request to Deputy
Commissioner of Enforcement, 2101 Arena Blvd, Sacramento, CA 95834 or email your request
to DFPIPeaceOfficerComplaint@dfpi.ca.gov.