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My Name My Email My Phone Alternate Phone Date/Time of Activity Location of Activiy Who committed the potential act, crime or violation? What exactly happened? Where did the potential act, crime or violation take place? When did it happen? How was the potential act, crme or violation committed? Do you know why the person committed the potential act, crime or violation? Who else has knowledge of the potential act, crime or violation? Did you report this potential act, crime or violation to anyone else? If yes, who? Would you like to be contacted regarding your submission? Additional Comments and/or Information

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