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SUITE/APT CITY/ST/ZIP TELEPHONE (AC) Address of Loss Type of Location DALLAS, TEXAS Zip Date Property Last Seen Time AM or PM (circle one) Date Property Discovered Missing Time AM or PM (circle one) REPORTING PERSON AND WITNESS INFORMATION (This is NOT Public Information) PERSON MAKING REPORT (RP) (If Different from Owner) Race Sex Birthday Contact Phone Name: () Home Address Other Phone Street: City: St: Zip: () PROPERTY QTY DESCRIPTION – (Serial Numbers if Available) COST EACH Additional Property Is To Be Entered On A Separate Sheet of Paper TOTAL COST Total Loss NARRATIVE : (Briefly describe what happened.)
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