Golden Valley County Sheriff's Departmentpatch
                                        Voluntary Statement


 I,_____________________, am not under arrest for, nor am I being detained for any
criminal offenses concerning the events I am about to make known to the Golden Valley County

Sheriff's Department.  I volunteer the following information of my of my own free will for whatever
purposes it may serve.  My date of Birth is _____/_____/_____, age _____.  My social security
number is  _____-_____-_______.  I live at ___________________________________________.
My home phone ___________________, Cell phone ___________________.

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I have read each page of this statement consisting of _____ pages, each page of which bears my
signature and corrections if any, bear my initials and I dated this the ______ Day of __________ Year______.

                                                                                                        _______________________________
                                                                                                         Signature of person giving statement

                                                                           Page _____of ______