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Complaint Form

Name
Phone
Address
City
State
Zip
Date/Time/Location of Occurence
Name of Officers Involved (if known)
Has any member of this Department attempted to discourage you, in any way, from bringing this matter to the attention of the Department?
1. Yes
2. No
If yes, whom?
Details (Please summarize your complaint, and include names of witnesses and any other factual, supporting information)
Date
Date
Date
I have given this statement voluntarily and find it to be correct to the best of my knowledge.
Signature

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