Witness/Victim Statement Form

I VERIFY THAT THE FACTS SET FORTH IN THIS STATEMENT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE OR INFORMATION AND BELIEF. THIS VERIFICATION IS MADE SUBJECT TO THE PENALTIES OF SECTION 4904 OF THE CRIMES CODE (18 PA CC 4904) RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES AND SECTION 4906 (18 PA CC 4906) RELATING TO FALSE REPORTS TO LAW ENFORCEMENT.

Full Name

Incident Number *

Describe the Incident *

Upload Pictures of Incident or Injuries

Investigating Officer if known

Email Address

Phone Number

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