SWORN STATEMENT FORM WINOOSKI POLICE DEPARTMENT

SWORN STATEMENT FORM
WINOOSKI POLICE DEPARTMENT
27 WEST ALLEN STREET, WTNOOSKI, VT 05404
(802) 6ss-0221
INCIDENT NUMBER:
NAME:
Fax: (802) 655-6427
OFFICER:
DOB:
ADDRESS:
PHONE:
DATE:
POB:
TIME:
Do you swear the statement you are about to provide is true and accurate to the best of your
knowledge and being aware that you are subject to the pains and penalties of peq'ury.
I, ( PRINT NAME )
, HEREBY SWEAR
(OR AFFIRM ) THAT THE PRECEDING STATEMENT IS TRUE AND ACCURATE TO
THE BEST OF MY KNOWLEDGE.
SIGNATURE:
DATE:
NOTARY PUBLIC:
DATE: