Confidential Investigation Report Intake Form - Attorney General Of The State Of New Mexico Page 3

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Street Address
City
State
Zip
Home Phone
Work Phone
Mobile Phone
INCIDENT INFORMATION
Date of Incident
Time of Incident
Location of Incident
Have you previously filed a complaint with the facility or any agency involved?
YES
NO
What was the response from the facility?
Has a complaint been filed with any other agency?
If yes, please name the agency.
YES
NO
Have you contacted an attorney?
If yes, please name the attorney.
YES
NO
Is there a court action pending in this matter or has there previously been a lawsuit related to this matter?
YES
NO

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