F.A.C.T.S. SUBMISSION FORM

Submitted by cpogorzelski on Tue, 03/16/2021 - 10:45

First Name

Last Name

County

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

DATE OF INCIDENT

If ongoing, leave blank

DESCRIPTION OF ISSUE

Please tell us in as much detail as you can what the problem is, the parties involved, whether or not the issue is ongoing, and what steps have been taken to resolve the problem.

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