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                           Please fill out as much information as possible.                          
* Required Information.  


 Section 1.  Your Information (Complainant)
 

          * Name:
* Today's Date:
       * Address:
            * City:
          * State:
         Zip Code:
   Home Phone#: - -  
   Work Phone#: - -     Ext.:   
      Alt Phone#: - -   

   Email Address:
                Sex:   Race:   Age:  yrs.
                                                                                                
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 Section 2.  The person or company with whom you are having a dispute
(Respondent) 
 
*  Name/Company:
Contact Person
     (if company):
* Date of Incident: mm/dd/yyyy e.g. 2/1/2004 or 10/15/2004
           * Address:
                * City:
              * State:
            Zip Code:
     Home Phone#: - -
      Work Phone#: - -     Ext.: 
         Alt Phone#: - -
                Sex:   Race:    Age:  yrs.
            
       
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 Section 3.  Additional Party Involved (Skip section if not applicable)
 

Additional Party    Involved:
 Name/Company:
 Contact Person
     (if company):
         Address:
              City:
              State:
          Zip Code:
   Home Phone#: - -  
    Work Phone#: - -     Ext.: 
       Alt Phone#: -   -   
              Sex:   Race:    Age:  yrs.
       
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 Section 4.  Additional Party Involved (Skip section if not applicable) 
 
Additional Party      Involved:
 Name/Company:
 Contact Person
     (if company):
         Address:
              City:
              State:
          Zip Code:
   Home Phone#: - -  
    Work Phone#: - -     Ext.: 
       Alt Phone#: -   -   
              Sex:   Race:    Age:  yrs.

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            Section 5.  Description of the Dispute
* HOW DID YOU HEAR ABOUT US?: 
* Briefly describe the type of dispute (example:auto repair, neighbor dispute, debt): 
 
* Briefly describe how you would like it resolved: 
 
 

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