Statement Form

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COLUMBIA CITY POLICE DEPARTMENT
STATEMENT FORM
NAME__________________________________________
DATE__________FILE #______________
DATE OF BIRTH_____________________________
CASE OF:__________________________________
DL#________________________________________
PAGE NO._______ OF ________ PAGES
EMPLOYER_________________________________
EMPLOYER PHONE_________________________
EMPLOYER ADDRESS_______________________
CITY_______________________STATE________
THE ABOVE STATES THAT
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
HEREBY CERTIFY THAT THE FOREGOING VOUNTARY INFORMATION IS TRUE AND CORRECT TO THE BEST OF
MY KNOWLEDGE.
WITNESS_____________________________________ SIGNED________________________________________________
WITNESS _____________________________________ PHYSICAL ADDRESS____________________________________
MAILING ADDRESS____________________________________
PRIMARY PHONE #__________________________SECONDARY PHONE #_____________________________________

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