Legal & declarations
Statement of an incident template (US)
A general template under US law. Laws differ from state to state, so check it against your state's law or with a lawyer licensed there. We are not a law firm and do not give legal advice.
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Preview — US standard
Incident Statement
Person Giving the Statement
Name: Your Name
Address: Your Address
Phone and email: Your Phone and Email
Role or connection to the incident: Role, such as Witness, Employee, Driver or Customer
Incident Details
Date: Incident Date
Time: Incident Time
Location: Exact Location
Others present: Names and Contact Details of Other People Present
Police, security or other report number: Report Number or None
What Happened
Describe Events in Order, in Your Own Words. Say What You Saw and Heard Yourself, and Mark Anything You Were Told by Others.
Injuries or Damage
Injuries to Anyone and Property Damage, or None Known
Actions Taken Afterward
Actions Taken, such as First Aid, Calls Made or People Notified
Supporting Material
Photos, Video, Documents or Other Evidence Attached or Known
Declaration
I declare that this statement is true and correct to the best of my knowledge and memory. I understand it may be used in an investigation, insurance claim or legal proceeding.
Signature: Your Signature
Printed name: Your Printed Name
Date: Signing Date
If required for court use: I declare under penalty of perjury under the laws of the State of Declaration State that the foregoing is true and correct. Executed on Execution Date at City and State.