Voluntary Statement Form - Salem Police Department
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1PAGE NO. ____
of
____PAGES
SALEM POLICE DEPARTMENT
VOLUNTARY STATEMENT
INCIDENT NO.
_______________________________
Name of person giving statement ______________________________________________ Age
DOB
___________________
_______
Address ____________________________________________________________________ Phone ______________
Occupation ___________________________________ Employer or Business ________________________________
Business Address _____________________________________________ Phone ______________________________
I understand that 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 Salem Police Department. Without being accused of or questioned about any criminal offenses
regarding the facts I am about to state, I volunteer the following information of my own free will for whatever purpose it may
serve.
I further understand that I may be required to testify in court to the information which I am about to state.
If this statement is made with the intention of filing a criminal or traffic complaint against an individual or individuals, I
understand that it will be reviewed by the Salem Police Department to determine if a crime has been committed. If it is the
determination of the Salem Police Department that no crime has occurred or that there is insufficient evidence to prosecute,
this statement will only be retained in Salem Police Department files. It will not be forwarded for prosecution.
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 fact contained herein are true and correct.
Dated at _____________________________________, this
day of ________________________________________
___________
Witness:
_____________________________________________________________
_________________________________________________________________________________
Signature of person giving statement
(Please DO NOT EMAIL THIS FORM. Please print the completed statement form,
sign in the signature field, and deliver the original statement to the investigating
officer responsible for the case.)
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