Voluntary Statement Form - Mcleansboro Police Department printable pdf download

Voluntary Statement Form - Mcleansboro Police Department

VOLUNTARY STATEMENT FORM

Case#:__________________________________

Statement From:

Name: (Last/First/Middle)________

____________________________________ Date of Birth:________________________ Gender M F

Home Address:_____________________________________________________City:______________________State:_________Zip:___________

Work Address: ______________________________________City:__ __________

____State:___ _________Zip:______________

Home Phone:_____________________________________ Work Phone__

Other:____________________________

Place Statement Taken:___

_____________

____________

_________Date: _ ____

____Time:___

_______

Warning! By Signing this document, I certify (or declare), under penalty of perjury under the laws of the State of

Illinois, that the foregoing statement is true and correct to the best of my knowledge. Furthermore, I am also

aware that making a false or misleading statement to a Public Servant is a crime which is punishable in a court

of law.

________________________________________________________________________________________________

Signature

Date

Voluntary Statement Form - Mcleansboro Police Department