SOP_NUMBER: 209.04-att-5
TITLE: Official Witness Statement Form
REFERENCE_CODE: IIB08-0001
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2021-02-18
WORD_COUNT: 642
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105935
URL: https://gps.press/sop-data/209.04-att-5/
SUMMARY:
This is a standardized form used by the Georgia Department of Corrections to document sworn statements from witnesses at correctional facilities. The form captures witness information, location details, and a sworn statement made under oath without coercion or inducement. Completed forms are retained locally for three years with the related incident report before being destroyed.
KEY_TOPICS: witness statement, sworn statement, affidavit, incident report, facility investigation, witness testimony, statement form, correctional facility, GDC form
ATTACHMENTS:
1. Use of Force Supplement Report
URL: https://gps.press/sop-data/209.04-att-1/
2. Use of Force Incident Report
URL: https://gps.press/sop-data/209.04-att-2/
3. Use of Force Coversheet_Checklist
URL: https://gps.press/sop-data/209.04-att-3/
4. Conducted Electrical Weapon (Taser) Weekly Usage Report Example
URL: https://gps.press/sop-data/209.04-att-4/
5. Official Witness Statement Form
URL: https://gps.press/sop-data/209.04-att-5/
6. Restraint Chair Authorization Form
URL: https://gps.press/sop-data/209.04-att-6/
========================================================================
FULL TEXT:
========================================================================
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.