Complainant Name:        Home Phone:       Work Phone:

Address:       City:      State:       Zip Code:

Date of Birth:            

Driver's License Number:      License State:


Occurrence Location:     Occurrence County (if known):

Date of Occurrence:     

Time of Occurrence:   :  

Name of Employee Involved:      Employee Agency:

Name of Additional Employee Involved:      Additional Employee Agency:

Name of Witness:      Name of Additional Witness:

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By clicking on the “Submit” button as my electronic signature, I hereby certify that every statement I have made in this complaint is true and complete to the best of my knowledge. I understand that any false statement made in connection with this complaint may be subject to the provisions of S.C. Code §16-17-725.