OHIO DEPARTMENT OF PUBLIC SAFETY
OHIO INVESTIGATIVE UNIT
Complaint Referral Form
DATE:      
COMPLAINANT: (You may remain anonymous)              May we contact you? 
         Yes    No - I wish to remain anonymous
NAME   

PHONE

  
 

         Instructions:  
ADDRESS              Complete this form to the best of your knowledge.
             Click the SUBMIT button at the bottom to complete
CITY  STATE ZIP CODE           the process.
     

 

RETAIL STORE/INDIVIDUAL INFORMATION
NAME OF STORE      SUSPECT
    
CLERK/OWNER' NAME (if known)      ADDRESS
    
ADDRESS      CITY STATE ZIP
    
CITY STATE ZIP    OCCUPATION/PLACE OF EMPLOYMENT
  
COUNTY        SSN SEX BIRTHDATE/AGE
      
TOWNSHIP (if known)        RACE WEIGHT HEIGHT
      
         ANY ADDITIONAL INFORMATION HAIR EYES
        

DETAILS OF COMPLAINT


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