GPO42STMT City of Griffin Police Department Victim / Witness Statement Form GA1260100 Case #/G - ISHS Page_/ of _/_ Statement of (Victim / Witness) taken by Officer Deol a~ ee the Griffin Police Department on Lee (2. 20/6 at approximately 7327 Name ecsicm, Boynton Addre: “ BiG SSN: : Mayr loved ath ae po acct Hor et teeiete Isha’ Ades MTP oe Ponth, —“‘Uutingy enc “ira BeeeneT See t-¥ agi, ‘age read he above staloment and do hereby solemnly swear under eral enaty of a FELONY for FALSE SWEARING, ‘GGA 16-10-74, of FALSE STATEMENTS OCGA 16-10-20, antic punishment by not lass than one year nor more than ‘years of penal servitude andlor a fe of 19 and up to $1000.00, thatthe statements contained herein % ON Da ee ate” Heel and volintarty without fea ef treal ares eto ees é i: i lig signature) 141260100