SOP 209.04-att-5: Official Witness Statement Form

SOP 209.04
Attachment 5
2/18/21

|WITNESS STATEMENT|Col2|Col3|Col4|
|---|---|---|---|
|PLACE|DATE|TIME|FILE NUMBER
|
|LAST NAME, FIRST NAME, MIDDLE NAME|EMPLOYEE ID NUMBER|EMPLOYEE ID NUMBER|STATE ID NO.
|
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|
|
SWORN STATEMENT|
SWORN STATEMENT|
SWORN STATEMENT|
SWORN STATEMENT|
|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:















































|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:















































|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:















































|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:















































|
|EXHIBIT|INITIALS OF PERSON MAKING STATEMENT|INITIALS OF PERSON MAKING STATEMENT|
PAGE 1 OF _____ PAGES|
|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT ___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT ___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT ___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT ___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|

(Reproduced locally)

Retention Schedule: Upon completion, this form shall be maintained locally for three (3) years, with the Incident Report, and then
destroyed.

SOP 209.04
Attachment 5
2/18/21

|STATEMENT (Continued)|Col2|
|---|---|
|
AFFIDAVIT|
AFFIDAVIT|
|I, __________________________________________________ HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1
AND ENDS ON PAGE ______. I FULLY UNDERSTAND THE CONDITIONS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I
HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS
STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL
INFLUENCE, OR UNLAWFUL INDUCEMENT.


____________________________________________________________
(Signature of Person Making Statement)
WITNESS
Subscribed and sworn to before me, a person authorized by law
_______________________________________________ to administer oaths, this ____ day of ___________________, 20__
_______________________________________________ at ______________________________________________________
_______________________________________________
INSTITUTION OR ADDRESS
____________________________________________________________
(Signature of Person Administering Oath)
_______________________________________________
_______________________________________________
____________________________________________________________
_______________________________________________ (Typed Name of Person Administering Oath)
INSTITUTION OR ADDRESS

____________________________________________________________
(Authority to Administer Oath)
|I, __________________________________________________ HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1
AND ENDS ON PAGE ______. I FULLY UNDERSTAND THE CONDITIONS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I
HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS
STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL
INFLUENCE, OR UNLAWFUL INDUCEMENT.


____________________________________________________________
(Signature of Person Making Statement)
WITNESS
Subscribed and sworn to before me, a person authorized by law
_______________________________________________ to administer oaths, this ____ day of ___________________, 20__
_______________________________________________ at ______________________________________________________
_______________________________________________
INSTITUTION OR ADDRESS
____________________________________________________________
(Signature of Person Administering Oath)
_______________________________________________
_______________________________________________
____________________________________________________________
_______________________________________________ (Typed Name of Person Administering Oath)
INSTITUTION OR ADDRESS

____________________________________________________________
(Authority to Administer Oath)
|
|INITIALS OF PERSON MAKING STATEMENT|
PAGE OF PAGES
|

Retention Schedule: Upon completion, this form shall be maintained locally for three (3) years, with the Incident Report, and then
destroyed.