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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.
| Signature: _________________________ | Date: _________________________ |
Resolution / Outcome (if any)
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| Reported by: _________________________ | Date: _________________________ |
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