voluntary statement

Golden Valley County Sheriff's Department

Voluntary Statement

I, _____________________________, am not under arrest for, nor am I being detained for any criminal offenses concerning the events I am about to make known to the Golden Valley County Sheriff's Department. I volunteer the following information of my own free will for whatever purposes it may serve. My date of Birth is ____/____/____, age ____. My social security number is ____-___-______. I live at ____________________________________________________________________________. My home phone ____________, Cell phone ____________.

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I have read each page of this statement consisting of ____ pages, each page of which bears my signature and corrections if any, bear my initials and I dated this the ______ Day of _______________________ Year ______.

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Signiture of person giving statement

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GV5312007