“My name is (name) and I am employed with the (agency name) as a (title). I am assigned to the (division name) Division and my assigned duty hours are ___ hours until __ hours.
It is my understanding that, on (day), (date) at (time) at (place) I was ordered to submit this statement by (name), (rank). I submit this statement at his/her order as a condition of 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 statement solely and exclusively for internal purposes and will not release it to any other agency. It is my further belief that this statement will not and cannot be used against me in any subsequent proceeding, including criminal proceedings other than disciplinary proceedings within the confines of the department itself.
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 other rights prescribed by law. Further, I rely specifically upon the protection afforded me under the doctrines set forth in Garrity vs. New Jersey, 385 U.S. 493 (1967), and Spevack vs. Klein, 385 U.S. 511 (1967), should this report (statement) be used for any other purpose of whatsoever kind or description.
Finally, from the information provided me to date, I have fully cooperated and have answered all issues presented to me to the best of my ability and recollection. However, I reserve the right to supplement and/or amend this statement should additional facts be brought to my attention through further investigation, subsequent reflection on the matter, because of an honest defect in perception of the event(s), or the common shortcomings of the human memory.”