VOLUNTARY STATEMENT FORM

Harvey Police Department

Name: (Last/First/Middle) _______________________________________________________ Date of Birth: _________________________ Gender M or F

Home Address: ____________________________________________________ City: _______________________ State: ____________ Zip: _____________

Home Phone: _________________________________ Work Phone: __________________________________ Cell Phone:____________________________

Place Statement Taken: _________________________________________________ Date: ________________________ Time: ________________________

Miranda Warning
1. You have the right to remain silent.
2. Anything you say can and will be used against you in a court of law.
3. You have the right to talk to a lawyer and have him present with you before or during any questioning.
4. If you want a lawyer but cannot afford one, one will be appointed to represent you at public expense.
5. If you waive your right to remain silent and later wish to stop answering questions, the questions will stop.
6. If you waive your right to have a lawyer present and later change your mind, the questioning will stop until you have talked with a lawyer.

Waiver or Rights
1. Do you understand each of these rights? ______________________________________________________________________
2. Are you willing to give up these rights and make a statement at this time?___________________________________________

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Warning! By signing this document, I declare that the foregoing statement is true and correct to the best of my knowledge.
Furthermore, I am also aware that making a false or misleading statement to a Law Enforcement Officer is a crime (ND 12.1-11-03)
which is punishable in a court of law.

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Signature Location Date

Statement Page: _____ of _____ Witnessed By: