Sheriff's Department. I volunteer the following information of my 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 ___________________.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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______.
_______________________________
Signature of person giving statement
Page _____of
______
