Voluntary Statement Form - City Of Milton Police Department
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1City of Milton Police Department
VOLUNTARY STATEMENT FORM
Officer
Page # ____ of ____
1000 Laurel Street, Milton, Washington 98354
Tel: 253-922-8735
Fax: 253-922-2706
Date Reported: ____________ Time Reported: ___________
INCIDENT LOCATION:
DATE OCCURRED:
TIME OCCURRED:
FROM:
TO:
FROM:
TO:
LAST NAME:
FIRST NAME:
MIDDLE NAME:
RESIDENT ADDRESS
CITY
STATE
ZIP
DATE OF BIRTH
RACE
SEX
HEIGHT
WEIGHT
EYES
HAIR
DRIVER’S LICENSE NUMBER & STATE
CELL PHONE
HOME PHONE
WORK PHONE
EMAIL ADDRESS
EMPLOYER
ADDRESS
CITY
STATE
ZIP
DOLLAR VALUE
LICENSE NUMBER
LICENSE STATE`
VEHICLE YEAR
MAKE
MODEL
BODY STYLE
COLOR(S)
VIN #
UNIQUE MARKINGS
INSURANCE?
PERMISSION TO DRIVE GIVEN?
DIVORCE/SEPARATION:
PAYMENTS DELINQUENT:
KEYS IN VEHICLE:
VEHICLE LOCKED?
KEY(S) NEEDED?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
(Print Name) 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 the Milton Police Department. Without being accused of any criminal offenses regarding the facts I
am about to state, I voluntarily provide the following information of my own free will, for whatever purpose it may serve.
I want charges filed in this matter (CHECK BOX): YES____NO ____
I, the undersigned declare the attached information is true and correct to the best of my knowledge. I will testify, in court, under
oath, to the facts related to my statement above and attached report. I understand that if I knowingly make a false or misleading
statement that I may be charged with violation of RCW 9A.76.175, false statements. If I am reporting a stolen vehicle or vessel, I
understand I am liable for all towing and storage costs incurred in the recovery of this vehicle or vessel. I certify under penalty
of perjury under the laws of the State of Washington that the foregoing statement is true and correct.
Print Name:
Signature:
Date:
Time:
Location:
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