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UBJECT: (Briefly state your question or concern and the solution you are requesting. Continue on back, if necessary. Your failure to be specific may result in no action being taken. If necessary, you will be interviewed in order to successfully respond to your request. (Do not write below this line) DISPOSITION: Signature Staff Member Date Record Copy - File; Copy - Inmate PDF Prescribed by 1551 This form replaces BP-148.070 dated Oct 86 and BP-S148.070 APR 94 PDF by P FILE IN SECTION 6 U.

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