STATEMENT OF SUSPECT/WITNESS/COMPLAINANT
*(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - SEE REVERSE)*
SUSPECT
WITNESS/COMPLAINANT
XX
SECTION I. STATEMENT INFORMATION
DATE
TIME
LOCATION (Bldg/Room No.) AND INSTALLATION
UNIT TAKING STATEMENT
REPEAT (If Known)
21 Jul 94
/630
AFOSI Detachment 401 Randolph AFB TX
AFOSI Detachment 409
OFFENSE
COMPLAINT
SECTION II. PERSONAL IDENTIFICATION (Print or Type)
NAME (Last, First, Middle Initial)
SSN
STATUS/GRADE
NEWTON, IRVING
USAF (RET) 0-4
LOCAL ADDRESS (Include Zip Code)
DATE AND PLACE OF BIRTH (If Required)
TELEPHONE HOME DUTY:
PERMANENT ADDRESS OR HOME OF RECORD (Include Zip Code)
MILITARY ORGANIZATION/EMPLOYER
DEROS
Same as Above
USAF Retired
N/A
SPONSOR INFORMATION (Name, Grade, SSN, Organization, Duty Phone)
N/A
SECTION III. ACKNOWLEDGEMENT OF OFFENSES AND 5TH AMENDMENT/ARTICLE 31 RIGHTS ADVISEMENT (Suspect Only)
1. I have been advised that I am suspected of the following offenses:
_________________________________________________________________
by _________________________________ (Rank and Full Name) who identified himself/herself as a _________________________________ (SP, special agent, etc.) and advised me that I have the following rights according to the 5th Amendment of the US Constitution/Article 31 of the Uniform Code of Military Justice (suspect initials on line next to each statement).
- [ ] a. I have the right to remain silent - that is to say nothing at all.
- [ ] b. Any statement I make, oral or written, may be used as evidence against me in a trial or in other judicial, non-judicial, or administrative proceedings.
- [ ] c. I have the right to consult with a lawyer.
- [ ] d. I have the right to have a lawyer present during this interview.
- [ ] e. I may obtain a civilian lawyer of my own choice at no expense to the government.
- [ ] f. I may request a lawyer any time during this interview.
- [ ] g. If I decide to answer questions with or without a lawyer present, I may stop the questioning at any time.
- [ ] h. MILITARY ONLY: If I want a military lawyer, one will be appointed for me free of charge.
- [ ] i. CIVILIANS ONLY: If I cannot afford a lawyer and want one, a lawyer will be appointed for me by civilian authorities.
2. I have read my rights as listed above and I fully understand my rights. No promises, threats, or inducements of any kind have been made to me. No pressure or coercion has been used against me. I make the following choice (suspect initials on line next to appropriate statement):
- [ ] a. I do not want a lawyer. I am willing to answer questions or make a statement or both, about the offense(s) under investigation.
- [ ] b. I do not want a lawyer and I do not wish to make a statement or answer any questions.
- [ ] c. I want a lawyer. I will not make any statement or answer any questions until I talk to a lawyer.
3. I fully understand my rights and that my signature alone does not constitute an admission of guilt.
_________________________________________________________ _________________________________________________________
(Signature of Suspect) (Signature of Witness/Interviewer)
AF Form 1168, JUN 91 PREVIOUS EDITIONS ARE OBSOLETE
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