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2. Person Making Complaint
3. Date of Birth
5. Home Address
7. City
8. State
9. Zip Code
11. Work Name
13. Work Address
15. City
16. State
17. Zip Code
19. Home Phone
20. Work Phone
21. Cell Phone
23. What is the best time to contact you?
25. Person against whom you are making the complaint*

    *If you do not know the person's name, please describe them below.

27. Date of incident
    Date of incident
28. Time occurred
    Time occurred
29. Case No.
31. Where did the incident take place?
33. Describe what happened

    Be specific as to what was said, and include information on any witnesses.

35. Electronic Signature Agreement

    I declare this to be a true and correct report and the information therein to be accurate.  I further understand that I may be criminally charged for filing a false report, under 18 Pa. C.S. §4904, relating to Unsworn Falsification to Authorities and 18 Pa. C.S. §4906, False Reports to Law Enforcement Authorities.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
37. Electronic Signature
38. Date
    Date
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field