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EMERGENCY 911

Non-Emergency 979.828.3299

EMERGENCY 911 Non-Emergency 979.828.3299

SWORN AFFIDAVIT

[{"type":"header","subtype":"h2","label":"SWORN AFFIDAVIT","className":"d-block"},{"type":"date","required":true,"label":"Date","name":"Date","className":"col-md-6"},{"type":"text","required":true,"label":"Time","name":"Time-","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div><br></div><div><br></div>Before me, the undersigned authority, appeared _____________________________ (Print Affiant's Name)<div><br></div><div>who after being duly sworn on his/her oath deposes and says:</div>","className":"d-block"},{"type":"text","required":true,"label":"Full Name","placeholder":"Last Name, First Name, Middle Name","name":"Full-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Age","name":"Age","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Birth","name":"Date-of-Birth","className":"col-md-6"},{"type":"text","required":true,"label":"Address","name":"Address","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"City","name":"City","className":"col-lg-4","subtype":"text"},{"type":"select","required":true,"label":"State","name":"State","className":"col-lg-4","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX","selected":true},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code","name":"Zip-Code","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Home Phone Number","name":"Home-Phone-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Work Number","name":"Work-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Cell Number","name":"Cell-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Driver's License Number or official identification number ","name":"Drivers-License-Number-or-official-identification-number","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Social Security Number","name":"Social-Security-Number","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"I HAVE BEEN INFORMED THAT UNDER TEXAS LOCAL GOVERMENT CODE, SECTION 143.123 THAT:<div><br></div><div>\"AN INVESTIGATOR MAY NOT CONDUCT AN INTERROGATION OF A FIREFIGHTER OR POLICE OFFICER BASED UPON A COMPLAINT BY A COMPLAINANT (PERSON) WHO IS NOT A PEACE OFFICER UNLESS THE COMPLAINANT (PERSON) VERIFIES THE COMPLAINT IN WRITING BEFOREA PUBLIC OFFICER WHO IS AUTHORIZED BY LAW TO TAKE STATEMENTS UNDER OATH.\"</div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<br><div><br></div><div>In order to conduct a complete and thorough investigation of your complaint, we need you to answer the following questions. Please be as specific as possible.</div>","className":"d-block"},{"type":"date","required":true,"label":"Date of Incident","name":"Date-of-Incident","className":"col-md-6"},{"type":"text","required":true,"label":"Time of incident","name":"Time-of-incident","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Location of Incident","name":"Location-of-Incident","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Number of Robertson County Deputies/Employees involved","name":"Number-of-Robertson-County-DeputiesEmployees-involved","className":"d-block","subtype":"text"},{"type":"textarea","required":true,"label":"List any names, badge numbers, vehicle numbers and/or license plate numbers, And/or provide physical descriptions of the Deputies/Employees involved.","name":"List-any-names-badge-numbers-vehicle-numbers-andor-license-plate-numbers-Andor-provide-physical-descriptions-of-the-DeputiesEmployees-involved","subtype":"textarea","className":"d-block"},{"type":"text","required":true,"label":"Number of Witnesses who observed the incident","name":"Number-of-Witnesses-who-observed-the-incident","className":"col-md-6","subtype":"text"},{"type":"textarea","required":true,"label":"Provide full names, addresses, phone numbers, and any other identifying data. if there are no witnesses, please write the word \"NONE\"","name":"Provide-full-names-addresses-phone-numbers-and-any-other-identifying-data-if-there-are-no-witnesses-please-write-the-word-NONE","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Did you sustain any injuries?","name":"Did-you-sustain-any-injuries","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, please list the type of injuries which were a result of this particular incident.","name":"If-yes-please-list-the-type-of-injuries-which-were-a-result-of-this-particular-incident","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Did you receive ant medical attention?","name":"Did-you-receive-ant-medical-attention","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, please provide the name, address, and telephone number(s) of any doctor's office and/or hospital, as well as the date you received treatment.","name":"If-yes-please-provide-the-name-address-and-telephone-numbers-of-any-doctors-office-andor-hospital-as-well-as-the-date-you-received-treatment","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Were you arrested?","name":"Were-you-arrested","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Were you issued any tickets?","name":"Were-you-issued-any-tickets","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, to either question, please list the charges filed and/or citations issued and the disposition.","name":"If-yes-to-either-question-please-list-the-charges-filed-andor-citations-issued-and-the-disposition","subtype":"textarea","className":"d-block"},{"type":"textarea","required":true,"label":"Please give a detailed accounting of what happened.","name":"Please-give-a-detailed-accounting-of-what-happened","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<br><div><br></div><div>I have completed ____ years of school and can read and write the English Language. I have read this statement in its entirety and certify that its correct and true to the best of my knowledge.</div><div><br></div><div><br></div><div>_______________________________________ (Name: Printed)                                             ______________________________________________ (Signature)</div><div><br></div><div><br></div><div>Subscribed and sworn to before me this ___________ day of ________________, ________.</div><div><br></div><div><br></div><div>Notary Signature: ________________________________________________     (Notary Stamp/Seal)</div><div><br></div><div><br></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<br><div><br></div><div><br></div><div>(NOTE: A typed or handwritten statement may be attached in lieu of section 8 of this document. However, the document must be dated and signed in the presence of a Notary Public). All pages of the statement must be dated and initialed.</div>","className":"d-block"}]