Information
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Document No.
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Reference No.
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Conducted on
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Prepared by
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Location
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Personnel
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Statement in the matter of
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Date and time of statement
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Photo of person making statement
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Name of person making statement
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Address of person making statement
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Occupation
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States: This statement made by me accurately sets out the evidence which I would be prepared, if necessary, to give in court as a witness. The statement is true and to the best on my knowledge and belief and I make it knowing that, if it is tended in court as evidence, I shall be liable to prosecution if I have wilfully stated anything which I know to be false or do not believe to be true.
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Identity Number
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Residential Address
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Contact Number
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Employed by
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Work Contact Number
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Employed as (position)
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Period Employed
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I am years of age
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Statement
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Name of Person taking statement
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Signature of Person taking the statement
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Name of Person making the statement
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Signature of person making statement
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Name of Witness
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Witness to signature
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Date Signed
