
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER MUST
BE INDICATED.
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF
PREVIOUS EDITIONS ARE OBSOLETE.
DA FORM 2823, NOV 2006
DATEDTAKEN AT
APD AEM v1.04ES
SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is PMG.
PRIVACY ACT STATEMENT
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
To document potential criminal activity involving the U.S. Army, and to allow Army officials to maintain discipline,
law and order through investigation of complaints and incidents.
Title 10, USC Section 301; Title 5, USC Section 2951; E.O. 9397 Social Security Number (SSN).
Information provided may be further disclosed to federal, state, local, and foreign government law enforcement
agencies, prosecutors, courts, child protective services, victims, witnesses, the Department of Veterans Affairs, and
the Office of Personnel Management. Information provided may be used for determinations regarding judicial or
non-judicial punishment, other administrative disciplinary actions, security clearances, recruitment, retention,
placement, and other personnel actions.
Disclosure of your SSN and other information is voluntary.
3. TIME
6. SSN
I,
8. ORGANIZATION OR ADDRESS
10. EXHIBIT 11. INITIALS OF PERSON MAKING STATEMENT
1. LOCATION
5. LAST NAME, FIRST NAME, MIDDLE NAME
4. FILE NUMBER
7. GRADE/STATUS
, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
9.
2. DATE (YYYYMMDD)
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