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SWORN STATEMENT

For use of this form, see AR 190-45; the proponent of this form is ODCSOPS | |

|PRIVACY ACT STATEMENT |

|AUTHORITY: Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397Dated November 22, 1943 (SSN) |

|PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately recorded. |

|ROUTINE USES: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval. |

|DISCLOSURE: Disclosure of your social security number is voluntary. |

|1. LOCATION |2. DATE (YYYYMMDD) |3. TIME |4. FILE NUMBER |

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|5. LAST NAME, FIRST NAME, MIDDLE NAME |6. SSN |7. GRADE/STATUS |

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|8. ORGANIZATION OR ADDRESS |

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|9. |

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|I, ________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH: |

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|10. EXHIBIT |11. INITIALS OF PERSON MAKING STATEMENT | |

|      | |PAGE _____ OF _____ PAGES |

|ADDITIONAL PAGES MUST CONTAIN THE HEADING “STATEMENT ___________ TAKEN AT __________ DATED ________.” |

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|THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER MUST BE INDICATED. |

DA FORM 2823, DEC 1998 DA FORM 2823, JUL 72 IS OBSOLETE USAPA V1.00

|USE THIS PAGE IF NEEDED. IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED TO FINAL PAGE OF THIS FORM. |

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|STATEMENT OF ____________________________ TAKEN AT ____________________________ DATED ____________________________ |

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|STATEMENT (Continued) |

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|INITIALS OF PERSON MAKING STATEMENT | |

| |PAGE _____ OF _____ PAGES |

PAGE 2, DA FORM 2823, DEC 1998 USAPA V1.00

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|STATEMENT OF ____________________________ TAKEN AT ____________________________ DATED ____________________________ |

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|STATEMENT (Continued) |

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|AFFADAVIT |

|I, ________________________________________________________________, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1, AND ENDS ON PAGE ____.|

|I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH|

|PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL |

|INFLUENCE, OR UNLAWFUL INDUCEMENT. |

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|INITIALS OF PERSON MAKING STATEMENT | |

| |PAGE _____ OF _____ PAGES |

PAGE 3, DA FORM 2823, DEC 1998 USAPA V1.00

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(Signature of Person Making the Statement)

Subscribed and sworn to before me, a person authorized by law to administer oaths, this _____ day of ____________ ______.

at ____________________________________________________

(Signature of Person Administering Oath)

(Typed Name of Person Administering Oath)

(Authority to Administer Oath)

WITNESSES:

_______________________________________________________

_______________________________________________________

_______________________________________________________

ORGANIZATION OR ADDRESS

_______________________________________________________

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ORGANIZATION OR ADDRESS

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