| Type of Incident: | Referee |
| Match Number: | |
| Date of Incident: | 2012-09-15 |
| Time of Incident: | 08:30:00 |
| Location of Incident: | ROLLING HILLS MIDDLE SCHOOL - EL DORADO HILLS |
| Competition: | 2012_SOR_FALL_ |
| Home Team: | ETHOS |
| Visiting Team: | SACRAMENT UNITED SC - 12B GUNNERS |
| Age Group and Gender: | U12B |
| Team Affiliation of Individual Committing Incident: | |
| Incident Summary: | Complaint about Referee |
| Comments: | The assignor is aware of this situation and has taken action. |
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