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UNITED STATES SOCCER FEDERATION
REFEREE REPORT
This report must be mailed within 48 hours after completion of game to proper authorities
GAME:
Home Team
Score
Visiting Team
Score
State Association/
EPYSA
Division/
Age Group
Describe Any Unusual Incident:
Remarks:
Referee Signature:
Date:
Phone #:
SSN:
For serious assault, severe injury, or other substantial occurrences, a photo copy must be sent to Federation Headquarters: Fax: (312) 808-9572