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Civil Rights Questionnaire

Name
Mailing Address  
      Street Address
      City 
      State
      Zip
E-Mail Address
Phone Numbers
Date of Birth
Date of Incident
Law enforcement agency or other governmental unit responsible
Description of Incident
What Injuries did you suffer?
What other losses did you suffer?
Have you filed a charge, complaint or grievance with any governmental agency or court? Yes    No
      If so, when did you
      file?
Have you received a decision or response? Yes    No
      If so, when was it
      received?
 
 

 
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