Police Department
Office
385.201.1005
Fax
385.201.1006
580 West State Street
Lehi, UT 84043
lehi-ut.gov
PERSONAL INFORMATION AND STATEMENTS OF FACTS
Today’s Date: _________________ _____________________________
Case #
Location of Incident:_____________________________________________________________________________
Date of Incident: ____________________ Time of Incident: ________________ AM PM
Your Name: Last:_______________________________ First:_______________________________ MI:________
Address:___________________________________________ City:_____________________ ZIP:___________
Phone #: __ __ __________ Work#: __ _ ___________
SSN: _________ Driver’s License # ____________________________________
D.O.B.: ____________________ Sex: M F
Email Address: ____________________________________________________________________________________
Notice
Pursuant to Section 76-8-504.5 Utah Code annotated, you are notified that statements you are about to make may be
presented to a magistrate or a judge in lieu of your sworn testimony at a preliminary examination. Any false statement you
make that you do not believe to be true may subject you to criminal charges as a Class “A” misdemeanor.
Initial: ______
Narrative & Statement of Facts
Please be detailed in your description of the events and facts of this incident. Include what you saw, heard, or know of the
incident. When referring to an individual use their full name.
Narrative
Signature:_________________________________________________
Email Form
Print Form
Signature:__________________________________________________________
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