c
 

I, the undersigned affiant, a Lawful Man or Woman over the age of majority, not enlisted or commissioned in
any military service, competent to testify to and having first-hand personal knowledge of the facts, in good faith,
with no malice or intent of improper purpose such as to mislead, intimidate, harass, cause unnecessary delay, or
increase litigation cost, and under penalty of perjury under the laws of the United States of America and the
below identified State, do hereby timely certify the following averments as materially true, accurate, correct, and
complete, to wit: that I know and witnessed the events set forth below regarding the Target, circumstances,
date, time, location, Case #, and as further delineated.
Case # ___________________________ Date: _________________ Time: ________ AM PM Floor: _____ Room: ______
Address/Location: ___________________________________________________________________________________
Target Name ___________________________________________________________ Badge # _____________________
Basis for Knowledge of events ___________________________________________________________________________

Y
Affiant says nothing further. Signed and sealed with all rights reserved.
_____________________________________ _____________________________ __________
Executed by Affiant - Signature with All Rights Reserved

Affiant Printed Name

On this Date

_____________________________________________________________________________
Affiants Mailing Address

STATE OF

Y Y Y Y YY
________________________

COUNTY OF

________________________


 YY Y Y Y Y Y

Sworn to (or affirmed) and subscribed before me on ___ (day) ___________ (month), ______ (year) by the
Affiant identified above,  personally known, or  produced identification of type ____________________.
(Notary Seal)

_________________________________________________
Notary or First Witness Signature
____________________________________________________________
Notary or First Witness Name

_____________________________________________________________________________
First Witnesss Mailing Address

________________________________________ ____________________________________
Second Witness Signature with All Rights Reserved

Witness Name

_____________________________________________________________________________
Second Witnesss Mailing Address