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2. Name
4. Date of Birth
   Date of Birth
5. Sex

   1. Male
   2. Female
6. Race
8. Address
10. City
11. State
12. Zip Code
14. Phone
15. Work Phone
17. Email
19. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident
21. Location of Incident
23. Was someone arrested?

    1. Yes
    2. No
24. Name(s) of person(s) arrested:
26. Witness Names
28. Witness Address
30. City
31. State
32. Zip Code
34. Witness Phone
36. Name(s) of officer(s) involved:
38. Was a Police Report made?

    1. Yes
    2. No
40. Describe what happened and specify your complaint.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

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