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2. Please relate your complaint, include names, times, locations, witnesses, and any other factual supporting information. For complaints involving Racial or Identity profiling please indicate specific alleged profiling (specific race, ethnicity, nationality, age, religion, gender, gender expression, sexual orientation, mental disability or physical disability).
4. First Name*
5. Last Name*
7. Phone
8. Email*
10. Address
12. City
13. State
14. Zip
16. Today's Date*
    Today's Date
20. Date & Time of Occurrence
    Date & Time of Occurrence

    Date & Time of Occurrence
22. Location of Occurrence
24. Names & ID Numbers of Officers or Employees Involved*
    If known, please provide this information.
26. Details of Occurrence*
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field