Coleman-Baker Act

Date of Request

First Name of person requesting

Last Name of person requesting

Address of person requesting

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email address of person requesting

Phone number of person requesting

Date and Time of occurrence

Victim Name

Your relationship to victim

Case Number (if known)

Address or place of occurrence

Name and Badge number of person accepting request

To be filled out by DeKalb County Police Department

Request forwarded to and date

To be filled out by DeKalb County Police Department

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