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rev. 10/7/2016
VOLUNTARY WITNESS STATEMENT FORM
CLARK COUNTY
PUBLIC RESPONSE OFFICE
2911 E SUNSET RD, LAS VEGAS, NV 89120
Phone: 702-455-4191 – Fax: 702-455-2080
PublicResponseI[email protected]
CASE NUMBER: OFFICER: CE#:
DATE OF INCIDENT:
NATURE OF INCIDENT – INCLUDE ADDRESS OR LOCATION
PAGE ____ OF ____
WITNESS NAME:
DATE OF BIRTH:
ADDRESS:
PHONE NUMBER:
WITNESS SIGNATURE: DATE:
Your name, date of birth, address, and telephone number are requested in case additional information is needed or if you are
needed for a court appearance pertaining to this case. If you would like to remain anonymous, please do not complete this form as
we will not be able to use the information provided. If you provide your name or other personal information it may be disclosed,
even if you request to remain anonymous. All information collected by this agency is made available to the public in accordance with
the Public Records Act.