Victim / Witness Statement Form printable pdf download

Victim / Witness Statement Form

Town of Waterville Valley

Department of Public Safety

14 TAC Lane / P.O. Box 500 Waterville Valley, NH 03215

Victim / Witness Statement Form

Case Number:

Date:

My name is

and I live at

(Street)

(Town)

(State)

(Zip)

My Phone Number is: (Home) (Cell) (Other)

I am making the following statement concerning _____________________________________________ which occurred

(Location of Incident)

(Day)

AM/PM.

I am making this statement voluntary, without reward, promise of reward,

(Date)

threat or force, to _______________________________________________________________________________, a

police officer(s) of the Waterville Valley Police Department.

Continue on back if necessary.

Under penalties of Unsworn Falsification (RSA 641:3), I declare that I have read the foregoing statement and that the facts stated in it

are true.

_______________________________________

_____________________________________

Signature of Victim / Witness

Signature of Officer / ID Number

Sheet _________ of ________

Victim / Witness Statement Form