- Complaint Number:
- Complainant’s Name: Last, First, MI
- Date of Report:
- Home and/or Local Address:
- Home and/or Cell Phone:
- Business/School Name & Address:
- Business Phone:
- E-mail Address:
- Date of Occurrence:
- Location of Incident:
Read Section 641.3 of The New Hampshire Criminal Code, Unsworn Falsification. PRINT your FULL NAME on the proper line below Section 641.3, and enter your signature, the date, and time on the proper line at the bottom of the page.
“A person is guilty of a misdemeanor if: I. He or she makes a written or electronic false statement which he or she does not believe to be true, on or pursuant to a form bearing a notification authorized by law to the effect that false statements made therein are punishable; or II. With a purpose to deceive a public servant in the performance of his or her official function, he or she:
- Makes any written or electronic false statement which he or she does not believe to be true; or
- Knowingly creates a false impression in a written application for any pecuniary or other benefit by omitting information necessary to prevent statements therein from being misleading; or
- Submits or invites reliance on any writing which he or she knows to be lacking in authenticity; or
- Submits or invites reliance on any sample, specimen, map, boundary mark, or other object which he or she knows to be false.”
I, ________________________________________ (PRINT first, middle, last name), have read the above section of The New Hampshire Criminal Code and do hereby attest that I fully understand its contents.
- Signature:
- Date:
- Time:
- Description of Incident:
I do hereby affirm that the above information provided by me relative to this complaint is true and complete to the best of my knowledge and belief. I understand that any false, misleading, or untrue statements, accusations or allegations herein made by me or during the course of this investigation, in relation to this incident, either orally, or in writing, to any person or persons investigating this incident may subject me to civil and/or criminal prosecution. I fully realize that it may become necessary in the investigation of this incident for me to meet with a member of the PSU Police Department to discuss this issue. I agree, should any Administrative Hearing or Court proceedings result from the investigation of this incident, to make myself available to present testimony at such hearings if requested to do so.
- Complainant’s Signature:
Report Received By:
- Signature:
- Date:
- Time:
Psupd-1 (rev 8-1-08)
Overcast. Light Rain. Temperature: 38; Wind: W at 10; Conditions as of Sun May 26 at 03:00 AM EDT