Niobrara County Sheriff Office Statement Form

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NIOBRARA COUNTY SHERIFF OFFICE
STATEMENT FORM
FULL NAME OF WITNESS: ______________________________________DATE OF BIRTH: ___________
ADDRESS: ______________________________________TOWN: ______________________STATE: _____
TELEPHONE: (HOME): ___________________________ (WORK): ________________________________
DATE/TIME OF STATEMENT: ______________________________________________________________
TYPE OF CRIME: _____________________________________CASE NUMBER: _____________________
***WITNESS IS TO NOTIFY SHERIFF'S OFFICE OF CHANGE OF ADDRESS***
W.S. 6-5-210 False reporting to authorities; penalties.
(a)A person who knowingly reports falsely to a law enforcement agency or a fire department that:
(i)A crime has been committed is guilty of a misdemeanor punishable by imprisonment for not more than six (6) months, a fine of not more than seven
hundred fifty dollars ($750.00), or both;
(ii)An emergency exists is guilty of a misdemeanor punishable by imprisonment for not more than one (1) year, a fine of not more than one thousand dollars
($1,000.00), or both;
(iii)An emergency exists, when the false report results in any person suffering serious bodily harm, is guilty of a felony punishable by imprisonment for not
more than five (5) years, a fine of not more than five thousand dollars ($5,000.00), or both;
(iv)An emergency exists, when the false report results in the death of any person, is guilty of manslaughter punishable as provided in W.S. 6-2-105.
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Witnessed Signature by a Peace Officer
Signature to be witnessed
Niobrara County Sheriff's Office/revised 2013
Page_____ of _____ Pages

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