Witness Statement Form

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RUMFORD POLICE DEPARTMENT

Your full name *

Date of birth

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.

I acknowledge and agree with the disclaimer

I do not acknowledge or agree with the disclaimer

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