<p> FORM 12-11 LAW ENFORCEMENT OFFICERS’ BILL OF RIGHTS - EPD1200.0 EDMONSTON POLICE DEPARTMENT 5005 52ND Avenue Edmonston, Maryland 20781 (301) 699-8805 </p><p>Date: ______</p><p>TO: ______</p><p>FROM: ______</p><p>SUBJECT: Imposition of Disciplinary Action - ICN # ______</p><p>I have received and reviewed an investigative report prepared by ______concerning your actions of ______. </p><p>This report indicates a sustained finding. Therefore you are charged as follows:</p><p>Charge; ______</p><p>To Wit; ______In light of the aforementioned, I intend to take the following disciplinary measures.</p><p>WAIVER OR ACCEPTANCE OF PUNISHMENT</p><p>I do not dispute the facts as stated above.</p><p>I do accept the punishment as offered.</p><p>I do waive my rights to a hearing board as provided for in the Law Enforcement Officers' Bill of Rights.</p><p>If summary punishment is a letter of reprimand, I understand and accept this document as the official letter of reprimand.</p><p>I do dispute the facts as stated and do not accept the punishment offered. I request a hearing board as provided in the Law Enforcement Officers' Bill of Rights. </p><p>I do not accept the punishment, agree with facts, and request hearing.</p><p>RESPONDENT OFFICER'S SIGNATURE: ______</p><p>SERVED BY: ______DATE: ______TIME: ______FORM 12-11 LAW ENFORCEMENT OFFICERS’ BILL OF RIGHTS - EPD1200.0</p><p>NOTICE TO RESPONDENT</p><p>You must sign this form and indicate one or more of the above options. This form must be returned to the office of the Chief of Police, within seventy-two (72) hours of receipt. If this form is a letter of reprimand, and you accept it, the form will be placed in your personnel file.</p><p>Should you request a hearing, you are hereby advised that you have the right to legal representation or representation by someone of your choosing, and a hearing on the disputed issue(s) before an administrative hearing board in accordance with Public Safety Article-Title 3, Subtitle 1, Section 3-104 (J) and Section 3-107 (A). </p><p>Return Received By: ______Date: ______</p>