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Email Address*

Primer nombre*

Apellido*

Date of Birth

Fecha*

Texas Driver's License*

Dirección*

Main Phone*

Alternative Phone

Name of person you are complaining against*

Your Relationship (How do you know this person?)*

Date this incident occured

Fecha*

Did this happen in Harris County?*

Law Enforcement Agency Incident Reported to*

Offense Report Number*

Briefly summarize the major event of what happened*

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