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2. Contact Information:
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Home Phone Number
16. Cell Phone Number
18. Business Phone Number
19. Email Address
21. Incident Information:
23. Officer's Name and/or Badge Number*
25. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
26. Report Number (if known)
28. Please Describe What Happened*
30. Electronic Signature
    The undersigned certifies that the statements set forth in this instrument are true and correct.
32. Please Type Name in Space Below to Sign*
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34. 1. Receive an email copy of this form.
35. Email address

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36. Submit Submit and Print

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