Witness Statement Form
TOWN OF RUMFORD - ANIMAL CONTROL
Your full name *
Date of birth
MM
/
DD
/
YYYY
Your street address *
(Example: 124 Main Street, Apt. 4)
Your Town *
Your State *
Do you acknowledge and agree with this disclaimer? *
I hereby acknowledge that I am making the following statement without fear, threat, or promise. I acknowledge that I have been advised that any statement(s) made herein which I do not believe to be true, and which statement is intended to mislead a public servant in the performance of his/her official duties is a crime under 17-A M.R.S.A., section 453.
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