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DA FORM 2823, DEC 1998 DA FORM 2823, JUL 72 IS OBSOLETE USAPA V1.00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:
_______________________________________________________
_______________________________________________________
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ORGANIZATION OR ADDRESS
_______________________________________________________
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ORGANIZATION OR ADDRESS
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