TOWN of CANAAN POLICE DEPARTMENT

38 Church Street,Canaan, New Hampshire03741 CFS#__________________

UNIFORM STATEMENT FORM

Statement Given By: ________________________________________ Date of Birth: ____/____/_____

Address: _________________________________________________________________________

Home Phone: _____________

Work Phone: _____________

Interview Location: _________________________________________________________________

Date of Interview: _________________ Time : _________________

The following statement was given voluntarily by me to ______________________________, who was

identified to me as a member of the Canaan, New Hampshire Police Department.

____________________________, have advised the above-named individual of his/her Miranda

Rights, and have attached same to this statement.

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Signed: ___________________________  Page ____ of  ____

CONTINUATIONof UNIFORM STATEMENT FORM

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Signed: ___________________________  Page ____ of  ____