CITIZEN NAME (LAST,FIRST,MI)

RACE

SEX

DOB

DATE & TIME OF STATEMENT

ADDRESS

SSN

HOME PHONE

WORK PHONE

I am	of the Atlanta Police Department. By your making this statement
you are providing information in an investigation being conducted by the Atlanta Police Department. Please be advised that your statement and/or your testimony may be needed at a future time for use in a civil service hearing or court of law.

ATLANTA POLICE DEPARTMENT

CITIZEN STATEMENT

EMPLOYEE:	CITIZEN:	OPS #

I have read or had read to me the above statement and I swear or affirm that it is true to the best of my knowledge and belief.
CITIZEN SIGNATURE
Sworn and subscribed to me this
day of
in the year

PRINT CITIZEN NAME
NOTARY PUBLIC
P	-
-	1	-
Form APD-824 revised 1/1/2000

EMPLOYEE NAME (LAST, FIRST, MI)

AJordan

2004-03-10

Atlanta Police Department