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GRIEVANT’S NAIVIE: (L5" SBI#: [QU; S, /
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BRIEFLY STATE THE REASON FOR THIS GRIEVANCE. GIVE DATES AND NAMES OF OTHERS INVOLVED
THE INCIDENT OR ANY WITNESSES.
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WAS AN INFORMAL RESOLUTION ACCEPTED? (YES) (NO) ;
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GRIEVANT'S SIGNATURE: DATE:
IF UNRESOLVED, YOU ARE ENTITLED TO A HEARING BY THE RESIDENT GRIEVANCE COIVIMTITEE.
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Case 1 :06-cv-00011-SLR D0cLjment E39-2 .;¤~· Filed 09/07/2006 Page 2 of 2
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