Reporting Officer: Date:Badge #:
Signature:
Witness:
Signature:
Incident occurred on or between: Reported on:
Month: Month: Month:Day: Day: Day: Year:Year:Year: D.O.W.:D.O.W.:D.O.W.: Time:Time:Time:
Name: Last, First Middle: Race Hispanic
Y N
Sex Height: Weight: Eyes: Hair: Date of birth:
Home Address: City: State: Zip: Resident
Y N
Home Phone:
Work Phone: Cell Phone:Business Address: City: State: Zip:
Driver License Number: Social Security Number:
Age:
I have read each page of this statement consisting of ___ page(s), each page of which bears my signature and
corrections, if any, bear my initials, and I certify that the facts contained here in are true and correct.
Parent or Guardian if 17 years of age or younger
COWETA POLICE DEPARTMENT
VOLUNTARY STATEMENT
Case Number:
Marital Status:
Revised on 11-20-2019
M F
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