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C:/STAFF FORM/EMPLOYEE STATEMENT FORM/8.99
FIRE DEPARTMENT n CITY OF NEW YORK
EMPLOYEE STATEMENT FORM
Page
of
TO: FROM:
SUBJECT: DATE:
EMPLOYEE STATEMENT:
I affirm that all the facts set forth in this statement are true, complete and correct to the best
of my knowledge and belief. I was directed by my supervisor to provide a true account of the
matter(s) under consideration. The facts that I have provide are mine and were provided
without being influenced by any other party or person. I understand this statement will be used
for administrative purposes, and the information shall be subject to verification.
Employee’s Signature: Date:
Employee’s Name (print): S.S. #:
Witness’ Signature: S.S. #: