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2. Date & Time of Offense*
   Date & Time of Offense

   Date & Time of Offense
4. Victim*
6. Witness*
8. Suspect*
10. Location*
12. Reporting Party*
14. Phone*
16. Email*
18. Address*
20. City*
21. State*
22. ZIP*
24. Statement Details*
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26. 1. Receive an email copy of this form.
27. Email address

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28. Submit

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