witness_statement_formICR # _____________
City of Fridley
Police Department
VICTIM/WITNESS STATEMENT
DATE OF OFFENSE: ____/____/____ TIME OF OFFENSE: ____:____ am/pm
LOCATION OF OFFENSE: ______________________________________________________________
OFFENDER: _______________________________________________________ DOB: ____/____/____
Please use the space below to provide factual details concerning this incident. Whenever
possible include exact words used when relating statements made by involved parties.
Please include all relevant facts. You may continue on the reverse side of this page, if
necessary.
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I certify that the information provided by me on this document is true and correct to the best of my
knowledge. I understand that this statement will become a permanent part of the case file of this incident
and may be used in court. I also understand that knowingly making a false identification or making false
statements about a crime may subject me to possible criminal charges.
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Signature of Citizen Making arrest Date
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Printed Name (First, Middle, Last) Telephone Number(s)
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Address City State Zip
Fridley Police Department 6431 University Avenue NE, Fridley, Minnesota 55432 (763) 572-3629
Emergency Contact Information
Name: __________________ Name: __________________
Address: ________________ Address: ________________
Phone #: ________________ Phone #: ________________