For use of this form, see AR 190-45; the proponent agency is PMG.
PRIVACY ACT STATEMENT
Title 10, USC Section 301; Title 5, USC Section 2951; E.O. 9397 Social Security Number (SSN).
To document potential criminal activity involving the U.S. Army, and to allow Army officials to maintain discipline,
law and order through investigation of complaints and incidents.
Information provided may be further disclosed to federal, state, local, and foreign government law enforcement
agencies, prosecutors, courts, child protective services, victims, witnesses, the Department of Veterans Affairs, and
the Office of Personnel Management. Information provided may be used for determinations regarding judicial or
non-judicial punishment, other administrative disciplinary actions, security clearances, recruitment, retention,
placement, and other personnel actions.
Disclosure of your SSN and other information is voluntary.
2. DATE (YYYYMMDD)
4. FILE NUMBER
5. LAST NAME, FIRST NAME, MIDDLE NAME
8. ORGANIZATION OR ADDRESS
, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
11. INITIALS OF PERSON MAKING STATEMENT
PAGE 1 OF
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER
MUST BE INDICATED.
PREVIOUS EDITIONS ARE OBSOLETE
DA FORM 2823, NOV 2006
APD LC v1.01ES