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  2. 999-999-9999

  3. 999-999-9999

  4. Approximate date and time if exact time is unknown

  5. Address or approximate location

    Please select the option or options that best describes the nature of your complaint. You may select more than one option.

  6. Please fill out the name, approximate age and phone number of any witness to the events.

  7. As clearly and concisely as possible, please describe the incident in question.

  8. Signature or your typed name will be sufficient for this block

  9. Leave This Blank:

  10. This field is not part of the form submission.