SWORN STATEMENT - ArmyWriter.com

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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                   |

|                                                                      |                             |                             |                                 |

|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                                                                                 |                                              |

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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                                                                                 |                                              |

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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

_______________________________________________________

______________________________________________________________________________________________________________

ORGANIZATION OR ADDRESS

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