Police Verification Witness Statement Form
Provide the witness details and a clear statement to support police verification. Please complete all required fields accurately.
Witness Identity
Full Name
*
First Name
Middle Name
Last Name
Relationship to Person/Event
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Statement Details
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Statement Category
*
Please Select
Witnessed Event
Character Reference
Residence Confirmation
Identity Confirmation
Other Relevant Police Verification Context
Witness Statement / Narrative
*
Statement Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Confirmation and Submission
I confirm this statement is true and accurate to the best of my knowledge.
*
I confirm
Signature
*
Submit Statement
Submit Statement
Should be Empty: