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I.',CIU C/,SE COVER <br />.! <br />* ~J Dcpt Ho. _ MCIU <br /> <br />Defendant <br /> <br />DOB Offense <br /> <br />/ <br /> <br />Phone <br /> <br />inal Record specify or attach sheet <br /> <br />Location (specific address) <br /> <br />Time and Date of Offense <br /> <br />Est. value ta~<en Recovered <br /> <br />Damaged <br /> <br />,! <br /> <br />Property owner name (corporation) <br /> <br />ira(s) or Complainant(s) DOB Address <br /> <br />:A-~css Business phone. <br /> <br />/ <br /> Home phone <br /> <br />Biness phone Home phone ,~'.. Auto used Model <br /> <br />Lic. No. <br /> <br />Elnt of injuries (if any) Evidence - attach receipt if necessary, include <br /> photos <br /> Admlssions/Statements-Yes ( ) No ( ) <br /> <br /> nary: (Include applicable elements and detail to draw criminal complaint. Attach extra sheets if necessary.) <br /> <br />I <br />I <br /> <br />I <br />I <br /> <br /> <br />