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
Gender MaleFemale
Age
Occupation of deceased
Your occupation
Date of death
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
