PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 8013, 44 U.S.C. 3101, and EO 9397
PRINCIPAL PURPOSES: Used to record information and details of criminal activity which may require investigative action by commanders, supervisor, security police, AFOSI special agents, etc. Used to provide information to the appropriate individuals within DOD organizations who ensure that proper legal and administrative action is taken
ROUTINE USES: Information may be disclosed to local, county, state and federal law enforcement or investigative authorities for investigation and possible criminal prosecution or civil court action. Information extracted from this form may be used in other related criminal and/or civil proceedings
DISCLOSURE IS VOLUNTARY: SSN is used to positively identify the individual making the statement and as a conduit to check past criminal activity records
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SECTION IV. STATEMENT
THIS PAGE USED FOR SIGNATURE ONLY. TEXT OF STATEMENT BEGINS ON PAGE 3
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SECTION V. SIGNATURE/OATH
"I hereby voluntarily and of my own free will make this statement without having been subjected to any coercion, unlawful influence, or unlawful inducement. I swear (or affirm) I have read this statement, initialed all pages and corrections, and it is true and correct to the best of my knowledge."
(Signature of Person Making Statement)
(Signature of Witness/Interviewer)
Subscribed and sworn to before me, a person authorized by law to administer oaths, this 21st day of July 1994
(Signature of Person Administering Oath)
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SECTION VI. INSTRUCTIONS FOR CONTINUATION PAGE(S)
Use plain bond paper (both sides optional). At the top right of each page, print or type: “(Last Name of Individual making the Statement) on (Date).” At the bottom of each page, print or type: “Page ___ of ___ Pages”. The individual must initial the top and bottom entries and sign his/her name at the bottom of each page.
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AF Form 1168, JUN 91 (REVERSE)
*U.S. Government Printing Office: 1991 — 281-451/40139
Page 2 of 3 Pages