502.11E2 - Witness Disclosure Form

WITNESS DISCLOSURE FORM

 

 

Name of Witness: 

  

_____________________________________________________

Date of interview:

_____________________________________________________

Date of initial complaint: 

_____________________________________________________

Name of Complainant:  

_____________________________________________________

 

_____________________________________________________
   

Date and place of alleged incident(s): 

_____________________________________________________

 

_____________________________________________________

 

_____________________________________________________
   

 

Description of incident(s) witnessed: _________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

 

Additional information: _________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

 

I agree that all of the information on this form is accurate and true to the best of my knowledge. 

Signature: _____________________________________ Date:  __________________________