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Contact Information of Person filling out this report, if other than the victim. Include name, address, phone, & e-mail.

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Your signature immediately below indicates your consent to use this form in reports and presentations to various groups including the media. This refers to information only, actual names of victims will be withheld unless specifically agreed to in advance. You DO NOT have to sign here if you do not consent.

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Resolution / Outcome (if any)

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Reported by: _________________________ Date: _________________________


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