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Get AZ Reportable Event Record/Report 2017-2024

Ress: City/Zip Home Phone #: Work Phone #: Relation to Resident: (If any) State in your own words what you witnessed (be very descriptive) and sign below. The information provided above is true to the best of my knowledge. Signature of Witness Revised 11/07/2017 Date Page 4 of 4 .

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