Constitutional Protection Statement

"On ___________(date) ___________(time) at _____________(place) I was ordered to submit this report (give this statement) by _____________________(name & rank). I submit this report (give this statement) at his order as a condition of my employment. In view of possible job forfeiture, I have no alternative but to abide by this order."
"It is my belief and understanding that the department requires this report (statement) solely and exclusively for internal purposes and will not release it to any other agency. It is my further belief that this report (statement) will not and cannot be used against me in any subsequent proceedings. I authorize release of this report to my attorney or designated union representative."

"I retain the right to amend or change this statement upon reflection to correct any unintended mistake without subjecting myself to a charge of untruthfulness."

"For any and all other purposes, I hereby reserve my constitutional right to remain silent under the FIFTH and FOURTEENTH AMENDMENTS to the UNITED STATES CONSTITUTION and any other rights PRESCRIBED by law. Further, I rely specifically upon the protection afforded me under the doctrines set forth in Garrity v. New Jersey, 385 U.S. 493 (1967), and Spevack v. Klien, 385 U.S. 551 (1956), should this report (statement) be used for any other purpose of whatsoever kind or description."

To print, highlight area and press Control C, then open word processing program and press Control V. Then you may print the form out on paper.

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