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Complainant Information

Witness Information

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Date of Incident (mm/dd/yyyy)

Time of Incident (hh:mm:ss am/pm)

Officer

Agreement

By submitting this form, I affirm that the information provided is true to the best of my knowledge. I understand that any false, misleading, or untrue statements , accusations, or allegations herein made by me, in relation to this complaint, may subject me to civil suit or prosecution.

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