2346

SWORN STATEMENT

For use of this form, see AR 190-45; the proponent agency is PMG.

AUTHORITY:

PRIVACY ACT STATEMENT

Title 10, USC Section 301; Title 5, USC Section 2951; E.O. 9397 Social Security Number (SSN).

PRINCIPAL PURPOSE: To document potential criminal activity involving the U.S. Army, and to allow Army officials to maintain discipline,

law and order through investigation of complaints and incidents.

ROUTINE USES:

Information provided may be further disclosed to federal, state, local, and foreign government law enforcement

agencies, prosecutors, courts, child protective services, victims, witnesses, the Department of Veterans Affairs, and

the Office of Personnel Management. Information provided may be used for determinations regarding judicial or

non-judicial punishment, other administrative disciplinary actions, security clearances, recruitment, retention,

placement, and other personnel actions.

DISCLOSURE:

Disclosure of your SSN and other information is voluntary.

1. LOCATION

5. LAST NAME, FIRST NAME, MIDDLE NAME

2. DATE (YYYYMMDD)

3. TIME

4. FILE NUMBER

6. SSN

7. GRADE/STATUS

8. ORGANIZATION OR ADDRESS

9.

I,

10. EXHIBIT

, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:

11. INITIALS OF PERSON MAKING STATEMENT

PAGE 1 OF

ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF

TAKEN AT

PAGES

DATED

THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER

MUST BE INDICATED.

DA FORM 2823, NOV 2006

PREVIOUS EDITIONS ARE OBSOLETE

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STATEMENT OF

TAKEN AT

DATED

9. STATEMENT (Continued)

INITIALS OF PERSON MAKING STATEMENT

PAGE

DA FORM 2823, NOV 2006

OF

PAGES

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STATEMENT OF

9. STATEMENT

TAKEN AT

DATED

(Continued)

AFFIDAVIT

I,

, HAVE READ OR HAVE HAD READ TO ME THIS...