Fillable Printable Statement of Witness

Statement of Witness

STATEMENT OF WITNESS

(Attach additonal sheets if necessary)

1. DID YOU SEE THE

ACCIDENT?

2. WHEN DID THE ACCIDENT HAPPEN?

A. TIME

a.m.

p.m.

B. DATE

3. WHERE DID THE ACCIDENT HAPPEN? (Give street location and city)

4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED

5. WHERE WERE YOU WHEN THE ACCIDENT OCCURRED?

6. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?

7. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY

8. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY

9. IF TRAFFIC CASE GIVE

APPROXIMATE SPEED OF:

a. GOVERNMENT VEHICLE

b. OTHER VEHICLE

MPH

10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (If known)

A. NAMES

B. ADDRESSES

WITNESS

COM-

PLETING

THIS

FORM

11. HOME ADDRESS (INCLUDE ZIP CODE)

12. WITNESS (PRINT OR TYPE NAME)

SIGN

HEREA

A. HOME TELEPHONE NO.

B. TODAY'S DATE

TELEPHONE NO.

13. BUSINESS ADDRESS (INCLUDE ZIP CODE)