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File a Statement with the MCC Police Department

File Statement

Date Form Filled Out

(month/day/year)

First name

Last Name

MCC Employee/Student ID#

Street Address

City

State

ZIP code

Phone number

Location of Incident

MCC Police Case # (if known)

Date and Time Incident Occurred

Details

Please describe the incident to the best of your knowledge. Include names and phone numbers of witnesses or persons involved.

Signature

My signature and/or submission verifies that this statement is correct and true as written.

Date signed

(month/day/year)

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