Student:
Student Yes Student No Incident #:
Incident #
Last Name:
Last Name First Name:
First Name
Middle:
Middle Date of Birth:
Date of Birth
Local Address:
Local Address
City:
City State: State Zip: Zip
Local Phone:
Local Phone Home Phone:
Home Phone
Cell Phone:
Cell Phone
Home Address:
Home Address
City:
City State: State Zip: Zip
Date of Statement:
Date of Statement Time of Statement: Time of Statement Time of Statement AM Time of Statement PM
I hereby make the following voluntary statement to:
Chief Matthew Kiederlen
Sgt. Jason Burt
Sgt. Steve Hanekamp
Lt. Matthew Schwartz
Officer Ryan Dewing
Officer Michael Sacco
Det. Cal Servi
Officer Nicolas Thompson
Officer Jeffrey Von Alven
Officer Kelsey Servi
Officer Savier Rodriguez
Officer Dan Kuehl
Officer Joushua Kuehl
Who has identified himself/herself to me as a member of the University Police. No threats or promises have been made to me to cause me to make this statement. I do so of my own free will.
Who has identified himself/herself to me as a member of the University Police. No threats or promises have been made to me to cause me to make this statement. I do so of my own free will
I have read (or had read to me) the above statement and find it is true and correct to the best of my knowledge and belief.
Signature: Signature
Date: Date
