Appendix A.

Latest version.

SWORN STATEMENT OF COMPLAINT

Name of ComplainantAddressCityTel. No.

Name of LicenseeAddressCityTel. No.

State Harness Racing Commission
Harrisburg, Pennsylvania
COMMONWEALTH OF PENNSYLVANIA

COUNTY } ss:

, being
(Name of Complainant)
first duly sworn deposes and says that
(Write in a brief

statement of the act complained of.)

                    
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