Royalton Police Department

VOLUNTARY STATEMENT

VERMONT SUPERIOR COURT
STATE OF VERMONT
CASE NUMBER:

Person Giving Statement:
Date of Birth:
Address:
City/Town:
State:
Zip:
Phone Number: Cell Land Line.
Email:

I , have read or have had read to me this statement which begins on page and ends on page . I fully understand the contents of the entire statement made by me. The statement is true. I have initialed all corrections and have initialed the bottom page containing the statement. I have made this statement freely without hope of benefit or reward, without threat of punishment, and without coercion, unlawful influence, or unlawful inducement under the pains and penalties of perjury.
Initials - I fully understand and aware, I am making this statement of my own free will, and with out any threats or promises extended to me by a Law Enforcement Officer or member of the Royalton Police Department.

Title 13 Vermont Statutes Annotated § 2901; § 2904. False swearing; false declaration;
(a) A person of whom an oath is required by law, who willfully swears falsely in regard to any matter or thing respecting which such oath is required, shall be guilty of perjury and punished as provided in section 2901 of this title.
(b) A person who declares, certifies, or verifies in a signed writing that a statement is true and is made under the pains and penalties of perjury, and who willfully makes a false statement in the declaration, certification, or verification, shall be guilty of perjury and punished as provided in section 2901 of this title.


Signed and sworn before me on this day of ,

______ Initials