(NOT UNDER ARREST) Case:
_________ญญญ___
I, __________________________________________,
am not under arrest for , nor am I being detained for
any criminal
offenses concerning the events I am about to make known to
______________________________________________.
without
Officers name and rank
being accused of or questioned about any criminal offense regarding the facts
I am about to state, I volunteer the following
information of my own free will, for
whatever purpose it may serve.
Phone:
( ) - .
I am _____________ years of age, my D.O.B. is ______/______/________, my SSN: ________-______-_______ and I live at __________
No.
____________________________________________________________________.
Street
City or town
State Zip code
STATEMENT OF FACTS OR INFORMATION
I
have read each page of this statement consisting of _________ page (s), each
page of which bears my signature, and corrections, if any, bear my
Initials, and I certify that the facts contained are true and correct.
.
Date:
_________/_________/________
Signature of person giving
statement
Witness: _________________________________