SEÑOR JUEZ DE POLICIA LOCAL DE CONCON

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_____________________ RUT__________________________, con domicilio en
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en causa Rol Nº_______________, Fono_______________ Correo electrónico
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Respetuosamente a Usía digo:

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Por tanto;
Ruego a U.S., se sirva acceder a lo solicitado.

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C.I. Nº____________________