Date

Time 24 hr

Location

Statement of ________ (B: year/month/day)

Street address, city, province, phone number

Q: Tell me what happened

A:____________

Q

A

Q

A

Q

A

Q: Is there Anything else you wish to add and is the above statements true to the best of your knowledge ?

A:________ 

Signed by victim/witness                                                                                              Witness (You)

End time 24 Hr

to end it off Z'd out bottom then sign it so nobody can add stuff