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2. COMPLAINT INFORMATION
4. Name
6. Current Address
8. City
9. State
10. Zip Code
12. Phone
13. E-mail
14. Cell Phone
16. INCIDENT INFORMATION
18. Date of Incident
    Date of Incident
20. Incident Location
21. Incident Time
23. Witness
24. Witness
25. Witness
27. Name of Officer or Employee
29. STATEMENT OF ALLEGATION
31. SIGNATURE
33. I authorize the verification of the information on this form. I understand that this complaint will be investigated and if this complaint is false, I may be subject to civil and/or criminal action.
35. Please type your first and last name
37. Electronic Signature
38. Date
    Date
40. 1. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

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