Statement Form

Student: yes no Incident #:
Last Name: First Name:
Middle: Date of Birth:
Local Address: (street / residence hall)
City: State: Zip:
Local Phone: Home Phone:
Cell Phone:
Home Address:
City: State: Zip:
Date of Statement: Time of Statement: AM PM
I hereby make the following voluntary statement to:
Who has identified himself/herself to me as a member of the University Police. No threats or promises have been made to me to cause me to make this statement. I do so of my own free will.
I have read (or had read to me) the above statement and find it is true and correct to the best of my knowledge and belief.
Signature: Date: