STATE OF  ________________________


I, the undersigned witness, appeared as stated and I do hereby certify that the below statements are true:

I, as Witness to Proceedings, and a Lawful Man or Woman over the age of majority, and having firsthand knowledge of the facts herein, hereby timely state that I witnessed on the below date the following behaviors and activities in the room and location, and related to the Public Officer or Judge in the case as listed and numbered below. I do hereby certify the fact, truth, accuracy, and material completeness of my statements to the best of my knowledge and belief. Further, I have no intent of improper purpose such as to harass, cause unnecessary delay, or increase litigation cost:

Name of Case__________________________________________________ Case # ______________________

Date of event: ________________ Room: _______________________________

Address/Location: _______________________________________________________________________

Presiding Officer, Magistrate, or Judge: ____________________________________

Behaviors and Activities Witnessed:

Wherefore, I do certify that I have made truthful, honest and accurate statements above, to the best of my knowledge and belief. 

_______________________________________ Date:__________________
Signature of Witness to Proceedings

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Witness to Signature

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