Your Name (required)

Your Address

Your Email (required)

Your Phone

Your Preferred Time and Method of Contact

Did you lose a child or family member to police brutality?

Your child's/family member's full name

Date of Birth (required)

Gender
MaleFemale

Age (required)

Occupation of deceased

Your occupation

Date of death (required)

Did the deceased have any other siblings? If yes, please list their names, gender and ages.

Police Department(s) or Agency involved

City where death occurred

Name(s) of police(s) officer involved

Additional Information: (If available)

Link(s) to newspaper story or local news station video

Do you have an attorney? If yes, what is your attorney's name?

Your attorney's email address

Phone number

Do you give MAPB permission to contact your attorney if necessary?
YesNo

Police Chief's name

District Attorney handling the shooting case

District Attorney's email

District Attorney's phone number

Have you been in contact with your local state representative in regards to this shooting death?
YesNo

Are you currently working with any other organization? May we contact this organization on your behalf?
YesNo

If yes, please provide the name of the organization

Organization contact