AR 15-6 Investigation re: Death of a Detainee

\-1
DEPARTMENT OF THE ARMY
HEADQUARTERS 9TH INFANTRY DIVISION (MECHANIZED)
• OFFICT, OF THE STAFF JUDGE ADVOCATE
TIKRIT, IRAQ
REPLY
ATTENTION •
•!:`,

AFYB--JA-AL 07 September 2003
MEMORANDUM FOR Commander, 4th Infantry Division (IVIechanized), FOB Ironhorse, Tit, Iraq SUBJECT: AR 15-6 Investigation — Legal Review
1. In accordance with AR 15-6, paragraph 2-3, I have reviewed the AR 15-6 investigation into the '13 August 03 death of a detainee at Camp Warhorse. I make the following determinations:
a . The proceedings comply with the legal requirements.

b.
Errors in the proceedings, if any, do not have a material adverse effect on any individual'ssubstantial rights.

C.
Sufficient evidence supports the findings.

d.
The recommendations are consistent with the findings. 2.. The investigation is legally sufficient.

-
3. The point of contact is the undersigned at (DNVT) 53 4
CPT, A.
Administrative Law Attorney

6232

DOD 002666

1NDtX OF ENCLOSURES AND EXHWTS
ENCLOSURES:
I - Appdintment Orders
II - Rights Warning Certificate ­Ill - Rights Warning Certificate ­IV - Rights Warning Certificate -
V,- Rights Warning Certificate -
VI - Rights Warning Certificate -- 4-)
VII - Rights Warning Certificate -

-41-2
VIII —Rights Warning Certificate
IX - Rights Warning Certificate
X - Rights Warning Certificate -

EXHIBITS:
A. Coalition Authority Forces Apprehension Form
B. Sworn Statement,t , dated 14 Aug 03
C. Sworn Statement,t ated 15 Aug 03
D. Sworn Statement,t dated 16 Aug 03
E. Sworn Statement,t , dated 16 Aug 03
F. Sworn Statement,t , dated 16 Aug 03
G. Sworn . Statement,t i ated 16 Aug 03
H. Sworn Statementt dated 16 Aug 03
I. Sworn Statement,t atqd 16 Aug 03
J. Sworn Statement,t dated -16 Aug 03
K. Sworn Statement,t dated 16 Aug 03
L. Chronological Record of Medical Care.
62,

DOD 002667

DEPAIITMENT OF TIM ARMY
_
A: :c
C co, 64 FORWARD SUPPORT BATALLION
i. BRIGADE COMBAT TEAM, 4 INFANTRY DIVISION (M)
,-,- :- A LAD,
-IRAQ APO-AE- 09323
*
AZCZ,FC-C'
MEMORANDUM FOR Commander, Task Force Ironhorse, ATTN: Chief of Staff,
Fleadquarters, Task Force Irorthoise, Tikrit, Iraq
ARC --
Fitiftgs. and RecotuthendatiOns of Informal Investigation of de
Qn 13 August 2003, IraqiQ**:qpo sm4ty arrest
-
and medical
., conditions that Ted
4eports that 4e: tgin6e
anod.otheing, hot -oil the
2003 and was out bl
: The detainee was
.
Wadi! Vt4g-polga-Q-11
The detainee, was
cell ue to mortar fife and
rd nothing more frorn him
7 -
13f4
gliwe told hiir that he had
ci wante.,„
'the MPS-that
6i,alaating the new detainee s
reports that

62d4

DOD 002668

AFZC-FC-C

SUBJECT: Findings and Recommendations of Informal Investigation of death of Iraqi
detaine‘11.10,
..7.,- i
the detainee !..-: b 4 L/'!"7c -i/ ;ias,able to walk without assistance and through another detainee that spokeEnglish; she waable to determine that detainee 1111.111.11complained
nothing to be,
abnormal. She instructed the MPs to send him to E Co 204 FSB if he worsened-
keporfs that
4,Wo -elaiJ.--y s nstructed the MPs to give the detainee extra w
es in the nioniin ater and
g and evenina. She reports that she documented herellcOunt r and the MPs b
-
assisting her confirm she wrote a medical note but the note was
nolfound
h
during this investigation.
M approxiitmtPly'
600 She same day
cofilookoorlioksoiot-
cOMPlained,-oflqbotiAti.
3 0 .minutes-[6&tairie
as vomiting
stininoned but vas- not or
ea iJ 4FS -o
the detainee camp e M
Saw the detainee
ask the medi
ua
intra Qus
note f to 'rye tanatinscipis

without tesPiifatien or
ee had noels acid
to the adfi t
e0.e Was
g The, conditiOnst of the ds tainee:catnipore.adeqUate. The detainees are given. 5-6
bottlei of water a day Of mat to sit or lie on friot.e if they ask for it All of the detainees have .a rtigThey are released from their cells to use the restroom and to walk
jfpgle
courtyard at schedUlechimes but can also leave their cell if they request. The cavi p Consists of two large cells that are designed to hold 30-.35 adults each Therp, p.
smaller cells that
0
used to separate ddtAitio6s, With
. -4%1or power within the country, The MPs report that thereare to:u they have room for so overcrowding has been an evidence of garbage or trash. $' Clean Withbut an
cells are *anti and he Thete.is'tio.air conditioning or fans that circulate air. The therri. Detainees are
DOD 002669

AFZC-FC-C
SUBJECT: Findings and Recommendations of Informal Investigation of death of Iraqi
detaine
) CotFq
b7c--q
given three MRks,,,,a day but the MPs report that most of the detainees don't eat them asthey complain of theSinell and taste.
h.
An interpreter from the MI BN.is available on o asion but most of the time theMPs and medical pe(isbnnel rely on other detainees to he p with the language barrier. The
IV:rant-el-pre­
ter claims that he had talked with detainee iii.M111110 in the past but not during thisilicident and has no knowledge of any medical history on the detainee.
i.
The medical officers of E Co 204 FSB and the 1982 FST. Physicians, physician's assistants, nurse anesthetists, and registered nurses perform the medical evaluations and sick call duties at the detainee camp. Physicians and physician's assistants h'ave credentials to provide this type of medical care, however, nurse anesthetists and registered nurses due not have the same practicing privileges. Individual's credential
packets were not available for review.
2. RECOMMENDATIONS
a. All medical information and encounters should be documented. A paper trail
becomes significant and is standard of care throughout the world. Documentation
provides better care and protects those providing the care. Recommend that the initial
medical screening and all medical encounters and interventions be documented and

placed in the detainee's file.
b.
Ensure all providers providing medical care have the appropriate credentials and
skills. Many nurses have learned through their experiences how to care for individuals
but they do not have the authority to examine, diagnose, and treat medical conditions.
With that said, they may not have the knowledge base to recognize a problem that needs

further attention. Recorn
. mend that nurses and nurse anesthetists provide care within the
scope of their credentials. If nurses continue to provide care, recommend that the

supervising physician provide a guideline for them to follow and list the
conditions/procedures that they can perform autonomously and those conditions that need
to be referred to a physician or physician assistant. Also recommend that all

documentation be reviewed and signed by a physician with the appropriate credentials.
c. Interpreters are a must. It is apparent that many individuals had differing opinions
as to what detainee #111111111.was
complaining of and the designated interpreter was not , involved in any aspect of this case. Without the use of an interpreter and relying on
5
another detainee to bridge the language gap, it becomes a guessing game as to what an
individual is saying. If detainee madchest pain the night prior to his death, no
one was aware of it and that may be due to the language barrier. If this was known, his death may have been prevented. Recommend that an interpreter be readily available in all detainee camps, especially for the initial medical interview and during sick call.

62d6

DOD 002670

AFZC-FC-C
SUBJECT- • •

and Recommendations of Informal Investigation of death of Iraqi
detaine
6 -;1

d. Atitops,k-jo give a definitive cause of death, an autopsy is required. Without anautopsy I cannkLeom.ment on whether or not detainer/Mr/death was related to his living conditions, heat, medical care (or lack of), or underlying ailments. Recommend that future deaths of Iraqi detainees undergo autopsy so more can be learnedabout the cansativtTactOrs and can possibly help with future operations and care.
377.,The POC is the undersigned (DNVT 534-Vin

(0)

MAJ, MC BN Surgeon, 64 FSB
6287

DOD 002671

EPORT OF PROCEEDINGS BY INVESTIGATING OFFICER/BOARD OF OFFIC.ER
For use of this form, see AR 15-6; the proponent agency is OTJAG.
IF MORE SPACE IS REQUIRED IN FILLING OUT ANY PORTION OF THIS FORM, ATTACH ADDITIONAL SHEETS
SECTION I - APPOINTMENT
Appointed by
(Appointing authority)
on 15 August..2003
(Attach indoiitre 1: Letter of appointment or summary of oral appointment data.) (See para 3-15, AR 15-6.)
(Date).,:.

SECTION II - SESSIONS .
Tne (investigation) (board)
commenced at 21st CSH, LSA Anaconda, Balad, Iraq
at 1000 hours

(Place)
(Time)

on 16 August 2003
(ifa formal board met for more than one session, check here
. . Indicate in an inclosure the time each session began and

ended, the place, persons present and absent, and explanation of absences, if any.)
The following persons
(members, respondents, counsel)

present: were
(After each name, indicate capacity, e.g., President, Recorder, Member, Legal Advisor.)
The following persons
(members, respondents, counsel)
were absent:

(Include brief explanation of each absence.) (See paras 5-2 and.
AR 15-6.)

I
The (investigating officer) (board)

finished gathering/hearing evidence at 1330 hours
on 16 August 2003
(Time) (Date)

and completed findings and recommendations at
1800 hours

I
on 24 August 2003
(Time)
(Date)

SECTION - CHECKLIST FOR PROCEEDINGS
I A. COMPLETE IN ALL CASES
IYES NO1 NA 21 1

I
Inclosures (para 3-15, AR 15-6)

Are the following inclosed and numbered consecutively with Roman numerals:
(Attached in order listed)
i a.
The letter of appointment or a summary of oral appointment data?
I b. Copy of notice to respondent, if any? (See item 9, below) x

c.
Other correspondence with respondent or counsel, if any?

d.
All other written communications to or from the appointing authority?

e.
Privacy Act Statements

(Certificate,, if statement provided orally)?

.I
i f. Explanation by
the investigating officer or board of any unusual delays, difficulties, irregularities, or other problems
encountered (e.g., absence of material witnesses)?

g. Information as to sessions of a
formal board not included on page 1 of this report?
It. Any other significant papers

(other than evidence)

relating to administrative aspects of the investigation or board?
FOOTNOTES.. It Explain all negative answers on an attached sheet.
Z' Use of the MA column cons: Owes a positive representation, that the circumstances described in the question did not occur in this investigation

or board.

DA FORM 1 574, MAR 83
EDITION OF NOV 77 IS OBSOLETE.
Pop, 1 of 4 pages IJSAPA V I .20

DOD 002672

2 i Exhibits
69a Ta 3-th AR /5-6)
a. Are all items cifer,ed
i

N.hether or nor received) 1 I exhibits and attached to this report? or considered as evidence individually numbered or lettered as
b.
is an index of all exhibits offered
to Of consi
c.

Has the tesirmonyistaterne deredhy...investigating officer or board attached before the first exhibit?
an exhibit?

ni-of each witness been recorded verbatim or been reduced to written form and attached as
.:-.
d.
Are copies, descriptions;-
r; clepictions
jlbeloction of the originarevidence.indicaced?

(if substituted for real or documentary evidence)I e. properly authenticated and is Are descriptions or diagram's included of locations visited by the invesdeatine officer or board
f (para 3-6b, AR 15-6)?
Is each written stipulation attached as an exhibit and is each oral stipulation either reduced to writing and made an
exhibit or recorded in a verbatim record?
1 g.
,-,-

If official notice of any thatter waI taken over the objection of a respondent or counsel, is a statement of the matter
of which official notice was taken attached as an exhibit (
3 para 3-16d, AR 15-6)?

Was a quoriapresent when the board voted
on fin

B. C dings and recommendations
(paras 4-1 and 5-26, AR IS-6J?
OMPLETE.ONLY FOR FORMAL BOARD PROCEEDINGS

At the initial session, did the re (Chapter
5, AR 15 -6)
5 Was corder read, or determine that all participants had read, the letter of appointment

a quorum present at every session of the board

(para 5-2b, AR 15-6)? (para 5-3b, AR 15-6)?
6 Was each absence of any member properly excused
(para 5-2a„-IR I5-6)?

7 Were members, witnesses, reporter, and interpreter sworn, if required
(para 3-1, AR 15-6)?
8 If any members who voted on findings or recommendations were not present when the board received some evidence,
does the inclosure describe how they familiarized themselves with that evidence

Oxzr
a 5-2d, AR 1 5-6)?

C. COMPLETE ONLY IF RESPONDENT WAS DESIGNATED
9 Notice to respondents
(para 5-5, AR 15-6): (Section II, Clzapter 5, AR
15-6)

I a.
Is the method and date of delivery to the respondent indicated on each letter of notification?

b. Was

the date of delivery at least five working days prior to the first session of the board?
c.
Does each letter of notification indicate —

(1)
the date, hour, and place of the first session of the board concerning 1
(2)

that respondent?
the matter to be investigated, including specific allegations against the respondent, if any?

(3) the
respondent's rights with regard to counsel?

(4)

the name and address of each witness expected ro be called by the

(5)
corder

the respondent s rights to be present, present evidence, and call witn

d. reesses? ?
Was the respondent provided a copy of all unclassified documents in the case file?

If there were relevant classified materials, were
the

10 If any respondent was designated after the proceedings respondent and his counsel given access and an opportunity to examine them?
began

I a.
Was he properly notified (or otherwise was absent during part of the
(para 5-5, AR 15-6)? proceedings):
I b.
Was record of proceedings and evidence received in his absence made available for examination by him and his counsel
11 1 Counsel
(para 5-6, AR 15-6): kuru 5-4c, AR 15 -6)?
a. Was each respondent represented by counsel?
Name and business address of counsel:

(If counsel is a lawyer, check here 0 )
I b. Was

C. respondent's counsel present at all open sessions of the board relating to that respondent?
If military counsel was requested but not made available, is a copy
action taken on it included in the report (or, if oral, a summary)

(para 5-6b, AR 15-6)? of the request and the
12

If the respondent challenged the legal advisor or any voting member for lack of impartiality
Ia.
(para 5-7, AR 15-6):
Was the challenge properly denied and by the appropriate officer?

Did each member successfully challenged cease to participate in the proceedings?
!3 I Was the respondent given an opportunity to

(pare 5-8a, AR 15-6).
-

a
Be present with his counsel at all open sessions of the board which deal with any matter which concerns thatrespondent?
b.

Examine and object to the introduction of real and documentary evidence, including written statements?

c.

Object to the testimony of witnesses and cross-examine witnesses other than his own?

id.
Call witnesses and otherwise introduce evidence?
e. Testify as a witness?
If

Make or have his counsel make a final statement or argument
s 141 If requested, did the recorder (para 5-9, AR 15-6)?

assist the respondent in obtaining evidence in possession of the Government and inarrangine for the presence of witnesses
I (para 5-8b, AR 15-6)?
151
I Are all of the respondent's requests and objections which were denied indicated in the report of proceedings or in an

inclosure or exhibit to it
I
(para 5-11. AR 15-6)?

5
FOOTNOTES: V
Explain all negaaPe anSWerS on an =ached shev.
2 Use of
or board

ca/rain cons:kiZeS a pavnive represen:idon :Inn :he circuinvallees described in :he question did tux Occur in ;his Page 2 of 4 pages, DA Form 1574, Mar 83 . inves:ivuzion
DOD 002673

$
The SE(710Pq iV - Fi‘iDINGS (pare 3-10,
(investigating officer) (board),

having carefully considered the evidence, finds:
1
,
I
-5'
-,_

(SEE ATTACHED MEMO)
1
i
1
I
SECTION V - RECOMMENDATIONS
(para 3-11, AR 15-6)

In view of the above findings, the
(investigating officer) (board)

recommends:
(SEE ATTACHED MEMO)

Page 3 of 4 pages, DA 62S0 I I
F01711 1574, Mar 83
USAPA V1.20

DOD 002674

:ONt

;TH - AU iitN I iL:IA
IS REPORTT OF PROCEEDINos.:ui:1 coma 1)eiovi,, ndicate.
i IS COMPLETE AND ACCURATE.
the reason th qf an
in e space where.
ere his.

.signature should appear.) y voting member or %he recorder _fails to sign here. or in cec..tion
(Recordei-) • PL.-9/
-,t•
• le
egeoaatolnvestigating Officer) (President)
(Member)
(Member)
(11,1ember)
(Member)

SECTION VII - MINORITY REPORT
ITo the extent indicated in Inclosure (Dara 3-13, AR 15 -6)
I,
the undersigned do(es) not concur in the findinEts and recommendations of the board.
n the inclosure, identify by number each finding- and/or recommendation in which the dissenting member(s) doles) not concur. State the reasons for disagreement. Additional/substitutefindings and/or recommendations may be included in the inclosure.)
(Member) •
(Member)
SE CTION VIII - ACTION BY APPO
B • • • ITY

The findings and recommendations of the (para 2-3, AR 15-6)
(inves g
ating office]) (b. ord) are

substitution.$). (If the appointing authority returns the proceedings t (approved) (di a)proved) (approved with following exceptions/
I • I corrective action, attach that correspondence (r a summary, if oral) as a numbered inclosure.)
ter or board for Arther proceedings or

_7-))
YR C.'.t" ;It ;.Lt LIL)
RAYMOND T. ODWRNO
Major General, USA
Page 4 of 4 pages, DA Form 1574, Mar 83 Commanding - 621)1

,JSAPA . I.20

DOD 002675

DEPARTMENT OF THE ARMY
3d BRIGADE COMBAT TEAM
4th INFANTRY DIVISION (MECHANIZED)
BALAD, IRAQ APO AE 09323-2612

AFCZ-FC-JA
5 September 2003
MEMORANDUM FOR RECORD

SUBJECT: AR 15-6 Investigation - Detainee Death at 2d BCT Detainment Facility.
1. This is to claj-ify the missing signature of the Investigating Officer
on the DA Form 1574.

completed her investigation with . th findings and recommendations on 24 Aug
er investigation was complete except for the DA Form 1574
received a Red Cress Message and left the area before the DA Form 1574 could be complete
CT Legal Cell filled in the enclosed DA Form 1574 using the investigation.
did sian her findings and recommendations memorandum
.
2. FOC is the undersigned at 534-111111

SG, U NCOIC, 3d BCT Legal Cell
DOD 002676

DEPARTMENT OF THE ARMY
HEADQUARTERS TASK FORCE IRONHORSE
TgKR1T IRAQ

REPLY TO
ATTENTION OF,

AFYB-CG 15 August 2003
M EIVI ORA

NDUM,FOROM11111.1 C Company, 64th FSB
SUBJEGT.,:•• Appointment as a 15-6 Investigating Officer
1. You are hereby appointed an investigating officer pursuant to AR 15-6 and AR 210-7, paragraph 4-3, to conduct an informal investigation into the sheetig death of a detainee Additionally, you are to identify any systemic problems that the command can address and correct,
if necessary.

2. You will use infilrmal procedures under AR 15-6, Chapter 4. You will make specific findings
and recommendations on all relevant issues you identify in the 'course of your investigation.

If,

during your investigation, you suspect that persons you intend to interview may have violated any
provision of the Uniform Code of Military Justice (UCMJ) or any other criminal law, you must
advise them of their rights under the UCMJ, Article 31, or the Fifth Amendment, as appropriate.
Rights warnings and waivers will be documented on DA Form 3881. Provide each witness a
Privacy Act statement before you solicit any personal information. All witness statements will be
sworn and recorded on DA Form 2823.
3. Before roceeding with the investigation, contact
at 534-Ilifor an initial legal

briefing. ill serve as your primary legal advisor.
4. Your report, together with all evidence marked as exhibits, will be submitted to me in memorandum fonnat no later than ten days from the date you receive this memorandum. Submit any requests for delay to me either orally or in writing. You will obtain a written legal review
priorto submitting the completed investigation.

FOR THE COMMANDER:
COL, GS Chief of Staff
62J3

DOD 002677
22.'neEr, L3FitEIV1112,V.E.:-3t,FiCATE
For use of this form, see AR 180-30; The proponent agency is ODCSOPS
i I' L:1'

I
DATA REQUIRED BY THE PRIVACY A^T
i

AUTHORITY:
Title

10:,,UnitedStates Code, Section 3012(g)
PRINCIPAL PURPOSE:
ROUTINE USES:

To proy,);deCommanders and law enforcement officials with means by which information
Your may be accurately identified. DISCLOSURE:
SocialSecurity Number is used as an additional/alternate means of identification to facilitate riling and retrieval. Disclosure df your Social Security Nurhber is voluntary.
LOCATION kejk
. DATE

3. T

Ci L N91C th kep3
NAME (Last,..F"-st, &41)

8.
ORGA I TION OR ADDRESS
SSN
GRADE/STATUS

1111111111111111.0

PART - RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights

I1
The investigator'wnos e name appears below told rhe that he/she is with the United States Army
, .-
F.6 ;&_-74th

suspected/accused: /„..,--k-1 and wanted,to question me about the fyllqwing offenses) of which I am
_
1
I Before

he/she asked me any Vestions about the offensets however, he/the c___
a

de it clear to me thAl have the r owing rights:
I do not have to answer any question or say anything.

Anything I 1
say or do can be used as evidence against me in a criminal trial.

. !For personnel subject oche UCMJ I
63
have the right to talk privately to a iawyer before, during, and after questioning and to have a lawyer present with me
during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense toor both.
me,

(For civilians nor subject to the UCIV1J1
I have the right to talk privately to a lawyer before, during, and after
me during questioning. I questioning and to have a lawyer present withunderstand that this lawyer can be one that I arrange for at my own expense, or if
I
cannot afford a lawyer and want one, a lawyerwill be appointed for me before any questioning begins.

If i am now willing to discuss the offense(s) under investigation, with or without
speak privately with

a lawyer present, I have a right to stop answering questions at any time, or a lawyer before answering further, even if I sign the waiver below.
COMMENTS
(Continue on reverse side).

Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offensefs) under investigation and
having a lawyer present with me.

make a statement without talking to a lawyer first and without

WITNESSES (If available) 3.
SIGNATURE OF INTERVIEWEE
13. NAME (Type or Print) 1
ORGANIZATION OR ADDRESS AND PHONE

2a. NAME /Type or Print)
ORGANIZATION OR ADDRESS AND PHONE
ORGANIZATION OF INVESTIGATOR

Section C. Non
-waiver

1. i do not want to give up my rights
1=-1 I want a lawyer
0 I do not want to be questioned or say anything
SIGNATURE OF INTERVIEWEE

4 —
TACH THIS WAIVER CERTIFICATE TO
WORN STATEMENT

(DA FORM 2823) 1.16SECKIE
TLY EXECUTED BY THE SUSPECT/ACCUSED

DA FORM 3881, NOV 79
EDITION OF NOV 84 IS OBSOLETE
USAP.82

DOD 002678

PART it- RIGHTS WARNING PROCEDURE
THE WARNING

WARNING - Inform the suspect/acaQd of:
•

a. Your official position.
•
b.
Nature of offensels).

c.
The fact that he/she is a suspecii'actu

-S'ed.

2.
RIGHTS - Advise the suspect/accused of his/her rights as follows: "Before I ask you any questions, you must understand your rights."
a.
"You do not have to answer my questions or say anything."

b.

"Anything ydllsay or do can be used as evidence against you in a criminal trial."

c. (For personneNtilbjebt to the UCMJ) "You have the right to talk
privately to a laWyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer .

—
Do you understand your rights?"
(If the suspectlaccused says "no," determine what is not understood, and if
' necessary repeat the appropriate rights advisement. If the suspect/accused says "ye.s," ask the following question.)
"Have you ever requested a lawyer after being read your rights?"
(If the suspect/accused says "yes," find out when and where. If the request
was recent
Ile., fewer than 30 days ago),

obtain legal advice whether to
continue the interrogation. If the suspect/accused says "no," or if the prior
equest was not recent, ask him/her the following question.)

I can be a civilian you arrange for at no expense to the Government or a military
lawyer detailed for you at no expense to you, or both,"
- Of -

(For civilians not subject to the (.IC114_1)
You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins."
d.
"If you are now willing to discuss the offense(s) under investigation, with or without a lawyer present, you have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if you sign a waiver certificate."

Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you want a lawyer at this time?"
(If the suspect/accused says "yes," stop the questioning until he/she has a
I

lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a lawyer
present with you?"
fif the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on the other side of this form. If the suspect/accused says "yes," have him/her read and sign the waiver section of the waiver certificate on rhe other side of this
form.)
SPECIAL. INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning, Make notations on the
waiver certificate to the effect that he/she has stated that he/she understands his/her rights, does not want a lawyer, wants to discuss the offense(s) under investigation, and refuses to sign the waiver certificate.
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all
cases

the waiver certificate must he completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of street interrogation, completion may be temporarily postponed. Notes should be
kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
1. If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS (Continued)
1 2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper rightsadvisal.
NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.

WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
interrogation, the suspect displays indecisidn about requesting counsel (for

example, "Maybe I should get a lawyer."), further questioning must cease immediately. At that point, you may question the suspect/accused only concerning whether he or she desires to waive counsel. The questioning may not be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you
shouldn't need an attorney.")
REVERSE OF DA FORM 3881
DOD 002679

,JS liVARNiNG PROCEDUREIWAIVER CL.g . IFICATF
c; c _...--

For use of this form, see AR 190-30; the proponent agency is ODCSOPS (-1 -61i C1-13
-1( '---1--"
L-

ii
-DATA REQUIRED BY THE PRIVACY ACT
AUTHORITY:
Titla.:1,0 'United States Code, Section 3012(g)

. PRINCIPAL PURPOSE:
To prOide commanders and law enforcement officials with means by which information may be accurately identified.
P.OUTiNE USES:

Your Social Security Number is used as an additional/alternate means of identification to facilitata
-fiting and retrieval.
DISCLOSURE:

Disclosureof your Social Security Number is voluntary.
LOCATI

ON,--- DATE TIME
4. FILE NO. :I ,-
, /

1A-)'. Z--,/-''' 4 .-)-
--(,1-5 -9-

5. NAMEtrt
It't,.. 8.tORGA ATION OR ADDRESS
C 4,4-1, wt, p
6. SSNt
., GRADE/STATUS I
P Fc../ ri.,--3 Fl--t(k----,-----0---rk/t-
.„

PART I - RIGHTS WAtER/NON-WAIVER CERTIFICATE
Section A. Rights
The investigator whose name appears below told me that'he/she is with the United States ArrnY C-C6 (,,, 4 65 6 7667 4­
-- 6
N

and want d to question me about the following offensels) of which
am suspected/accused:
c_k__.• / 0.__0?'-cr-rk e,-,',,tj P (2 \Le.-,..---i--7t' of.o.:1-YLL,---e-9 ., Before he/she asked me any questions about the offensedjowever, he sh made it clear to m i at I ha the following rights:
1.
I do not have to answer any question or say anything.

2.
Anything I say or do can be used as evidence aqainst me in a criminal trial. (For personnel subject othe UCMJ I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me,

or both.
t.

- Or -(For civilians not subject to the UCMJ)
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one,
a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if I sign the waiver below.
COMMENTS (Continue on reverse side)
Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without having a lawyer present with me.
WITNESSES (If available) 3. SIGNATURE OF INTERVIEWEE . NAME (Type or Print)
ORGANIZATION OR ADDRESS AND PHONE 4. SIGNATURE OF INVESTIGATOR
a. NAME
5. TYPED NAME OF INVESTI ATO13
ORGANIZATION OR ADDRESS AND PHONE S. ORGANIZATION OF INVESTIGATOR
1.4/ 114.p c7 L. IA-Of SC_ C PE fSi& 8c7
Section C. Non-waiver

I do not want to give up my rights
. I want a lawyer . I do not want to be questioned or say anything
2. SIGNATURE OF INTERVIEWEE
ATTACH THIS WAIVER CERTIFICATE TO ANY SWORN STATEMENT
(DA FORM 2823) SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
DA FORM 3881, NOV 89 EDITION OF NOV 84 IS OBSOLETE
DOD 002680

PART II - RIGHTS WARNING PROCEDURE.
WARNING - Infolem the suspe'c'E.L
li,:cused of:
a.
Your official position.

b.
Nature of offense(s).

c.
The fact that he/she is a saspaaVaccused.
RIGHTS - Advise the suspect/accused,of his/her rights as follows:
"Before I ask you any questions, you must understand your rights."

a.
'You do not have to answer my questions or say anything."

b.
"Anything you ­

say or do can be used as evidence against you in a
criminal
c.
(For peiiii,11..'.)elsubject to the UCMJ) "You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer

"Do you understand your rights?" If If the suspect/accused says "no," determine what is not understood, and if
1
necessary repeat the appropriate rights advisement. If the suspect/accused says "yes." ask the following question.)
"Have you ever requested a lawyer after being read your rights?" a
llf the suspect/accused says " ,(es," find out when and where if the request
was recent (i.e., fewer than 30 days ago),
obtain legal advice whether to
continue the interrogation. If the suspect/accused says "no," or if the prior
request was not recent, ask him/her the following question.)

THE WARNING
can be a civilian you arrange for at no expense to the Government or a
military
lawyer detailed for you at no expense to you, or both."
- Or -
(For civilians not subject to the UCMJ)

You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins."
c. "If you are now willing to discuss the offense(s) under investigation, with or without a lawyer present, you have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if you sign a waiver certificate."
Make certain the suspect/accused fully understands his/her rights.

THE WAIVER
"Do you want a lawyer at this.time?"
(If the suspect/accused says "yes," stop the questioning until heishe
has a lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a
lawyer

present with you?"
(If the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on the other side of this form. If the suspect/accused says "yes," have him/her read
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning. Make notations on the waiver certificate to the effect that he/she has stated that he/she understands his/her rights, does not want a lawyer, wants to discuss the offense(s) under
'investigation, and refuses to sign the waiver certificate.
1 IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning
q
begins. If the waiver certificate cannot be completed at once, as in the case of street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
i. If the supsect/accused has made spontaneous incriminating statements
before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.

COMMENTS (Continued)
2.
If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper
rights advisal.

NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.

WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR HER RIGHTS DURING THE INTERROGATION PROCESS: If during the interrogation, the suspect displays indecision about requesting counsel (for example, "Maybe I should get a lawyer."), further questioning must cease
immediately. At that point, you may question the suspect/accused only concerning whether he or she desires to waive counsel. The questioning may not be utilized to discourag's a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you
shouldn't need an attorney.")
REVERSE OF DA FORM 3881
USAPA V2.01
sp a
if

DOD 002681

WARNf,NG PROCEDU;REPNANER
For use of this form, see AR 780-30; the proponent agency is ODCSOPS
s ?-bk;
DATA REQUIRED BY THE PRIVACY ACT
AUTHORITY:
Title 1Q. United States Code, Section 3012(g)
PRINCIPAL PURPOSE:
To prf;yide commanders and law enforcement officials with means by which information may be accurately identified.
I
ROUTINE USES:

Your Soci. alSecurity Number is used as an additional/alternate means of identification to facilitate filing and retrieval.
DISCLOSURE:
Disclosure'of your Social Security Njmber is voluntary.
LOCATION
,2. DATE
e-06 k) 1)1_0v/5x_, 0 II 1 3. TIME

FILE NO.
Arzn.9,,o-DD
.7-
(\-
ORGANIc-A-110N OR ADDRESS
111111116

PART I - RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights
1 The investigator who .r nn . i' / . p .-----,-1
appears below told me that heishe is with the United States Army
! . t''----`-9t(-) 'fl ----S i3 36c 7-
\ 't

1 suspected/accused: and wanted to question me about the following offensels) of which I em
• ,-,\--' .. --'c vV"-ek—''-1 .,1-4' 'CO c-,0 -.C:t't()(, ,rk3t-L-\. (,-).----k/ CSI r-t ..
„

g before he/she asked me any questions about the offena_-­
. e(s), howeve?Aeishe madkitylear to me that I have 6 followin r S ghts:
1
I do not have -to answer any question or say anything.
Anything I say or do can be used as evidence against me in a criminal trial.
(for personnel subject oche UCMJ

I have the right to talk privately to a lawyer before, during, and after questioning and to have a
lawyer present with me during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me,or both.
- or -
1
(For civilians nor subject to the UCMJ)

I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with
me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
4.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or

speak privately with a lawyer before answering further, even if I sign the waiver below.
5. COMMENTS
(Continue on reverse side)

Section B. Waiver
gI understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without
having a lawyer present with me.
WITNESSES (If available)

SIGNA TURE OF INTERVIEWEE
NAME (Type or Print)

ORGANIZATION OR ADDRESS AND PHONE
SIGNATURE OF INVESTIGATOR

2
ORGANIZATION OR ADDRESS AND PHONE
ORGANIZATION OF INVESTIGATOR

I Section C. Non-waiver
I do not want to give up my rights
I i ;11 I want a lawyer I
do not want to be questioned or say anything

I
2.
SIGNATURE OF INTERVIEWEE
!

ATTACH
THIS WAIVER CERTIFICATE TO ANY SWORN STATEMENT
IDA FORM 2823)

SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
DA FORM 3881, NOV 89
EDITION OF NOV 84 IS OBSOLETE
6
yist,PA 2.31

DOD 002682

PART ii - RIC-HTS WARNING PROCEDURE
THE WARNING
1.
WARNING - Inform the suspait/Iccuseci of:
can be a civilian you arrange for at no expense to the Government or a military

a. Your official position.
b. Nature of offense(s). ",1, lawyer detailed for you at no expense to you, or both."
- or -

c. The fact that heishe is a i':.isp#r/aacused.
(For civilians not subject to the UCMJ)

2. You have the right to talk privately to a
RIGHTS - Advise the suspect/accused of his/her rights as follows: lawyer before, during, and after questioning and to have a lawyer present with
"Before I ask you any questions, you must understand your rights." you during questioning. This lawyer can be one you arrange for at your owna. "You do not have to answer my questions or say anything." expense, or if you cannot afford a lawyer and want one, a lawyer will be
b.
"Anything you say or do can be used as evidence against you in a appointed for you before any questioning begins."criminal tridr"
d.
'If you are now willing to discuss the offense(s) under investigation,
(For personnel subject to the UCMJ) "You have the right to talk
with or without a lawyer present, you have a right to stop answering
privately,,to a lawyer before, during, and after questioning and to questions at any time, or speak privately with a lawyer before
have a lawyer present with you during questioning. This lawyer
answering further, even if you sign a waiver certificate." Make certain the suspect/accused fully understands his/her rights.

THE WAIVER
"Do you understand your rights?"
"Do you want a lawyer at this time?"

(If the suspect/accused says "no," determine what is not understood, and if
II

(If the suspect/accused says "yes," stop the questioning until he/she has a

necessary repeat the appropriate rights advisement. If the suspect/accused says lawyer. If the suspect/accused says "no," ask him/her the following question.)
I

"yes," ask the following question.)
I "At this time, are you willing to discuss the offense(s) under investigation and"Have you ever requested a lawyer after being read your rights?"
make a statement without talking to a lawyer and without having a lawyer
(If the suspect/accused says "yes," find out when and where. if the request present with you?"
(If the suspect/accused says "no," stop the interview and

was recent
(i.e., fewer than 30 days ago),
obtain legal advice whether to

have him/her read and sign the non-waiver section of the waiver certificate on
continue the interrogation. If the suspect/accused says "no," or if the prior
the other side of this form. If the suspect/accused says "yes," have him/her read
request was not recent, ask him/her the following question.)
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the
12 If the suspect/accused was questioned as such either without being advised
suspect/accused orally waives his/her rights but refuses to sign the waiver
of his/her rights or some question exists as to the propriety of the first

certificate, you may proceed with the questioning. Make notations on the
statement, the accused must be so advised. The office of the serving Staff

waiver certificate to the effect that he/she has stated that he/she understands Judge Advocate should be contacted for assistance in drafting the properhis/her rights, does not want a lawyer, wants to discuss the offense(s) under
rights advise!. investigation, and refuses to sign the waiver certificate.
NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised

IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases
accordingly should be noted in the comment section on the waiver

the waiver certificate must be completed as soon as possible. Every effort certificate and initialed by the suspect/accused.
should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of
WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
street interrogation, completion may be temporarily postponed. Notes should be
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
kept on the circumstances. interrogation, the suspect displays indecision about requesting counsel (for
example, "Maybe I should get a lawyer."), further questioning must cease
PRIOR iNCRIMINATING STATEMENTS: immediately. At that point, you may question the suspect/accused only
1. If the supsect/accused has made spontaneous incriminating statements

concerning whether he,or she desires to waive counsel. The questioning may not
before being properly advised of his/her rights he/she should be told that be utilized to discourage a suspect/accused from exercising his/her rights. (For

such statements do not obligate him/her to answer further questions.

example, do not make such comments as "If yob didn't do anything wrong, you shouldn't need en attorney.")
COMMENTS (Continued)
REVERSE OF DA FORM 8881
DOD 002683

PART II - RIGHTS WARNING PROCEDURE
THE WARNING

i.
WARNING - Inforfi'; the suspecqe:odused of: can be a civilian you arrange for at no expense to the Government or a military
a. Your official position.
lawyer detailed for you at no expense to you, or both."
b.. Nature of offense(s).
- or -
c. The fact that he/she is a suO'ectslaccLised.
(For civilians not subject to the UCMJ)
You have the right to talk privately to a

2.
RIGHTS - Advise the suspect/accused of hisiher rights as follows: lawyer before, during, and after questioning and to have a lawyer present with
"Before I ask you any questions, you must understand your rights."
you during questioning. This lawyer can be one you arrange for at your own
a. "You do not have to answer my questions or say anything."
expense, or if you cannot afford a lawyer and want one, a lawyer will be
b.
"Anything you say or do can be used as evidence against you in a appointed for you before any questioning begins,"
criminal trial.
d.
"If you are now willing to discuss the offense(s) under investigation,
c. (For pers9.7)ii-­
el subject to the UCMJ) You have the right to talk with or without a lawyer present, you have a right to stop answering
privately to-a" lawyer before, during, and after questioning and to questions at any time, or speak privately with a lawyer before
have a lawyer present with you during questioning. This lawyer

answering further, even if you sign a waiver certificate." Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you•understand your rights?"
, • "Do you want a lawyer at this time?"'
If the suspect/accused says "no," determine what is not understood, and if (If the suspect/accused says "yes," stop the questioning until heishe has a
I

necessary repeat the appropriate rights advisement. If the suspect/accused says lawyer. If the suspect/accused says "no," ask him/her the following question.)
"yes," ask the following question.)
"At this time, are you willing to discuss the offensels) under investigation and
"Have you ever requested a lawyer after being read ybur rights?"
make a statement without talking to a lawyer and without having a lawyer
(If the suspect/accused says "yes," find out when and where. if the request present with you?"
(If the suspect/accused says "no," srop the interview and was recent (i. e., fewer than 30 days ago),

obta;ri legal advice whether to

have him/her read and sign the non-waiver section of the waiver certificate on
continue the interrogation. If the suspect/accused says "no," or if the prior
the other side of this form. If the suspect/accused says "yes," have him/her read
request was not recent, ask him/her the following question.)
I
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the
2. If the suspect/accused was questioned as such either without being advised
suspect/accused orally waives his/her rights but refuses to sign the waiver of his/her rights or some question exists as to the propriety of the first
certificate, you may proceed with the questioning. Make notations on the statement, the accused must be so advised. The office of the serving Staff
waiver certificate to the effect that he/she has stated that he/she understands Judge Advocate should be contacted for assistance in drafting the proper
his/her rights, does not want a lawyer, wants to discuss the offense(s) under rights advisal.
investigation, and refuses to sign the waiver certificate.
NOTE:

If 1 or 2 applies, the fact that the suspect/accused was advised

IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases
accordingly should be noted in the comment section on the waiver

the waiver certificate must be completed as soon as possible. Every effort certificate and initialed by the suspect/accused.
. should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of
WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
street interrogation, completion may be temporarily postponed. Notes should be
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
kept on the circumstances.
interrogation, the suspect displays indecision about requesting counsel (for example, "Maybe I should get a lawyer."), further questioning must cease
PRIOR INCRIMINATING STATEMENTS:
immediately. At that point, you may question the suspect/accused only
1_ If the supsect/accused has made spontaneous incriminating statements concerning whether he or she desires to waive counsel. The questioning may not

before being properly advised of his/her rights he/she should be told that be utilized to discourage a suspect/accused from exercising his/her rights. (For

such statements do not obligate him/her to answer further questions.

example, do not make such comments as "If you didn't do anything wrong, you shouldn't need en attorney.")
COMMENTS (Continued)
REVFRSF OF DA FORM 3881 SARA V2.01
DOD 002684

.24-1TSt1---'20 1:F=1-UREP.Af.A.N7R _
For use of this form, see AR 190-30; the proponent agency is ODCSOPStb , rjr cs
DATA REQUIRED 3Y THE T-1 RIVACY ACT
AUTHORITY:

Tit14 1.0, United States Code, Section 3012(g)
PRINCIPAL PURPOSE:

To provide commanders and law enforcement officials with means by which information may be accurately identified.ROUTINE USES: Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval.DISCLOSURE':
Disclose Of your Social Security Number is voluntary.
2. DATE 3 TIME !:';
1/r) /1—rA.q
f -°.11 3 0
8. ORGAN)4ATION OR ADDRESS
7. RADE/STATUS
111.111111111111.1
1111

PART I - RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights

The investigator whose
name appears below told me that he/she is with the United States Army •
e.ntr-65t&r

and wantrkto question me abou the following offense(s) of which I am
I suspected/accused: • :h-t

a-t
OCCi-CLA

Before he/she asked me any questions about the offense(s), ho(d..ever, he/s ' e r\ciacie it clear to me tel have thein/lowing rights:
I 1.
I do not have to answer any question or say anything.

2.

Anything I say or do can be used as evidence against me in a criminal trial.

3.

it-or personnel subject oche UCfvi,i i have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me

during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me
ul ULM,
or-
(For civilians not subject to the UCIV1J)

I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer
1t
will be appointed for me before any questioning begins.
I 4.

If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if I sign the waiver below.
5. COMMENTS (Continue on reverse side)
Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and withouthaving a lawyer present with me. /1 WITNESSES Of available) ..SIG , ,,iiir. k ;
S

1 a. NAME (Type or Print)
,,A.

b. ORGANIZATION OR .ADDRESS /-
DDRESS AND PHONE
SI' NATURE OF INVESTIGATOR

2a.tNAME IT se or Print)
TYPED NAME OF INVESTIG TOR
L.,

I b.
ORGANIZATION OR ADDRESS AND "HONE

5. ORGANIZATION OF INVESTIGATOR
I
Section C. Non -waiver
I 1. I do not want to give up my rights '
0 I want a lawyer 0 I do not want to be questioned or say any;'-ling

SIGNATURE OF INTERVIEWEE

ATTACH THIS WAIVER CERTIFICATE TO ANY SWORN STATEMENT
(DA FORM 2823) ( I
SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
-

DA FORM -Ninv RQt
.R2R1
.o 1

DOD 002685

PROCEDURE/WAIVE-A CER ie
For use of this form, see AR 190-30; the proponent agency is ODCSOPS
, ,.. DATA ^sEP,UIRED BY THE PRIVACY ACT
1AUTHORITY:
Title 10, United States Code, Section 3012(g)
PRINCIPAL PURPOSE: To provide .•.

.;..'manders and law enforcement officials with means by which information may be accurately identified.
,,... information
!ROUTINE USES:
Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval.
1 DISCLOSURE:
Disclosure of your Social Security Number is voluntary.
LOCATIO N... 1 "t1 LA
2 . DATE 3. TIME
\O FILE NO.
_,e' ''''. . /la 4-
1t(--- 0 (3).- /A )6._ttk' 6 - (.,' / 6, 41-7..x.)3
5.tNAMEt(Last, First, il/11),.., \olid'
8..ORGAIIATION OR ADDRESS
o.tSSN 7.tGRADE/STAtS
PART I -RIGHTS WAIVER/NON -WAIVER CERTIFICATE
Section A. Rights

._, (,..::,,7) 6..., .4/ r-Z
, 7-..0"-—7—

The investigator whose name appes'rs below told me that he/she is with the United States Army .Se --1(7/
,--. and wanted to question me about the following offense(s) of which I am suspected/accused: 4 v7 ef....,' fi c.---0-„--,--L: . ,... ...).__V----(,"\_e2) -_,-(2„,,..-,
/I 0_¦9

• Before he/she asked me any questions about e
ovever, he/she made it
1,

ffense(s), ....rde-r to me thatAave the following rights:
i do not have to answer any question or say-anything.
2.
Anything I say or do can be used as evidence against Inc in a criminal trial.
3. (For personnel subject oche UCMJ.I
have the right to talk privately to a lawyer

before, during, and after questioning and to have a lawyer present with me during questioning. This lawyer can be a civilian lawyer I arrange for at no expense
to the Government or a military lawyer detailed for me at no expense to me, or both.
. -or -
(For civilians not subject to the UCMJ)

I have the right to talk privately to a lawyer

before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for
at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with or without
a lawyer present, I have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if I sign the waiver below.
5.tCOMMENTS (Continue on reverse side)
Section B. Waiver
I
understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without !
having a lawyer present with me.
WITNESSES Of available) 3. SIGNATURE OF INTERVIEWEE
0 NAME (Type or Print)
o.tORGANIZATION OR ADDRESS AND PHONE d.tSIGNATURE OF INVESTIGATOR 01.•""
\D 146, Lo'
2a. NAME (Type or Print)
TYPED NAME OF INVESTIGATOR \Of1(1
b.
0 GANIZATION OR ADDRESS AND PHONE 6. ORGANIZATION OF INVESTIGATOR
Section C. Non-waiver
I do not want to give up my rights
E. I want a lawyer
. I do not want to be questioned or say anything
2. SIGNATURE OF INTERVIEWEE
ATTACH
His WAIVER CERTIFICATE TO ANY SWORN STATEMENT
(DA FORM 2823) SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED DA FORM 3881, NOV 89 EDITION OF NOV 84 IS OBSOLETE l}3:4001 2.01
DOD 002686

PART II - RIGHTS WARNING PROCEDURE
THE WARNING

WARNING - Inforrii the suspecf%'84.ised of:

can be a civilian you arrange for at no expense to the Government or a military
a. Your official position. lawyer detailed for you at no expense•to you, or both."

b. Nature of offense(s).
- Or -
c. The fact that he/she is a suspect/accused.

(For civilians not subject to the UCMJ)
You have the right to talk privately to a

2.
RIGHTS - Advise the suspect/accused of his/her rights as follows: lawyer before, during, and after questioning and to have a lawyer present with

"Before I ask you any questions, you must understand your rights." you during questioning. This lawyer can be one you arrange for at your own

a. "You do not have to answer my questions or say anything." expense, or if you cannot afford a lawyer and want one, a lawyer will

be
b.
"Anything-ryou say or do can be used as evidence against you in a appointed for you before any questioning begins."

criminal. trial."u

d. "If you are now willing to discuss the offense(s) under investigation,
c. (For pers3rif=iel subject to the UCMJ) "You have the right to talk with or without a lawyer present, you have a right to stop answering
privately Io.a lawyer before, during, and after questioning and to questions at any time, or speak privately with a lawyer before
have a lawyer present with you during questioning. This lawyer answering further, even if you sign a waiver certificate."
•

Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you understand your , rights?"
"Do you want a lawyer at this time?" If the suspect/accused says "no," determine what is not understood,
and if (If the suspect/accused says "yes," stop the questioning until he/she has a necessary repeat the appropriate rights advisement. If the suspect/accused says
lawyer. If the suspect/accused says "no," ask him/her the following question.)
yes," ask the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
• "Have you ever requested a lawyer after being read your rights?"
make a statement without talking to a lawyer and without having a lawyer (If the suspect/accused says "yes," find out when and where. If the iequest (ft the
r, cent wit!' Y^"7" says "no stop the interview and
was recent /Le., fewer than 30 days ago), obtain legal advice whether to
have him/her read and sign the non-waiver section of the waiver certificate on
i continue the interrogation. If the suspect/accused says "no," or if the prior
the other side of this form. If the suspect/accused says "yes," have him/her read
request was not recent, ask him/her the following question.)
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the
suspect/accused orally waives his/her rights but refuses to sign the waiver
certificate, you may proceed with the questioning. Make notations on the
waiver certificate to the effect that he/she has stated that he/she understands
his/her rights, does not want a lawyer, wants to discuss the offense(s) under
investigation, and refuses to sign the waiver certificate.
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
1. If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS /Continued)
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper rights advise!.
NOTE: If 1 or 2 applies, the fact that the suspect/accused was advised
accordingly should be noted in the comment section on the waiver
certificate and initialed by the suspect/accused.

WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR HER RIGHTS DURING THE INTERROGATION PROCESS: If during the interrogation, the suspect displays indecision about requesting counsel (for example, "Maybe I should get a lawyer."), further questioning must cease immediately. At that point, you may question the suspect/accused only concerning whether he or she desires to waive counsel.-The questioning may not be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you
shouldn't need an attorney.")
6 3 0 3

REVERSE OF DA FORM 3881 USAPA V2.01
DOD 002687
litiARNINP Pf-30a--DUREIWANT=Fi 1.3 ERM-3CATE
For use of this form, see AR 190-30; the proponent agency is ODCSOPS
CLL'.

DATA REQUIRED BY THE PRIVACY ACT
AUTHORITY:
Title 10, t".thited States Code, Section 3012(g)
PRINCIPAL PURPOSE:

To provide,..;tocHanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:
Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval. DISCLOSURE:
Disclosure of yOul,:,.Social Security Number is voluntary.
LOCATION_,
. DATE TIME
4. FILE NO.
Cy.,-/A),,-
41-7- (93 /(0

NAME (Last, First, MO)'`
ORG41IfATION OR ADDRESS
6. SSN
1111111111111111111.1.1111.
11111111111111.

PART I - RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights
The investigator whose name appears below told me that he/she is with the United States Army
(7..)t--r-

and wanted to question the about the following effense(s) of which I am suspected/accused: t1,, 4 'kr 11.4.0t
.Ct•CL-roL-L----E, OCRt
Gra.2-14'c(--(

Before he/she asked me any questions about t64fense(s), lyow
ver, he/she made it to
to me tha aye the following rights:
I do not have to answer any question or say anything.

2.
Anything I say or do can be used as evidence against me in
a criminal trial.

3. (For personnel subject othe UCMJ.
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me
during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me, or both.
- or -
(For civilians not subject to the UCMJ)

I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with
me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer
will be appointed for me before any questioning begins.
!

14.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or
speak privately with a lawyer before answering further, even if I sign the waiver below.
COMMENTS (Continue on reverse side)
Section B. Waiver
•
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without naving a lawyer present with me.
WITNESSES (If available) -
3. SIGNATURE OF INTERVIEWEE
:4
1 a.tNAME (Type or Print)

a..
ORGANIZATION OR ADDRESS AND PHONE SIGNATURE OF INVESTIGATOR
2a. NAME Tv e or Print). ¦
..

TYPED NAM1E OF INVESTIGATOR
\IOC:

b
GANIZATION OR ADDRESS AND PHONE
6.tGANIZATION OF INVESTIGA
Section C. Non-waiver
I do not want to give up my rights
DtI want a lawyer
.

I do not want to be questioned or say anything
SIGNATURE OF INTERVIEWEE
ATTACH THIS WAIVER CERTIFICATE TO ANY SWORN STATEMENT
IDA FORM 2823)

SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
ru iVI3881,t
EDITION OF NOV 84 IS OBSOLETE USAPA 2.01
DOD 002688

PART - RIGHTS WARNING PROCEDURE
THE WARNING

WARNING - Inform the suSIDect/accusecYbff-c:
a. can be a civilian you arrange for at no expense to the Government or a military
Your official position.
• z r

lawyer detailed for you at no expense to you, or both."
b.
Nature of offense(s). .4..

c.
The fact that he/she is a suspect/acc(Ise0.' •

RIGHTS - Advise the suspect/accused of his/herTights as follows: "Before I ask you any questions, you must understand your rights."
a. You do not have to answer my questions or say anything."
b. "Anything you say-'ar do Can be used as evidence against you in a
criminal trial." "
c. (For personnel subjeetto the UCMJ) "You have the right to talk
privately to a lawyeaefore, during, and after questioning and to
have a lawyer present with you during questioning. This lawyer

• io you understand your rights?"
• the suspect/accused says "no," determine what is not understood, and
if
- or -

I
(For civilians not subject to the UCIVIJ)

You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with
you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins."
d.

"If you are now willing to discuss the offense(s) under investigation, with or without a lawyer present, you have a right to stop answering
questions at any time, or speak privately with a lawyer before
answering further, even if you sign a waiver certificate."
Make certain the suspect/accused fully understands his/her rights.
THE WAIVER

"Do you want a lawyer at thiS time?"
(If the suspect/accused says "yes," stop the questioning until he/she has a
cessary repeat the appropriate rights advisement. If the suspect/accused says
ask the following question.)
:ave you ever requested a lawyer'after being read your rights?" •
the suspect:accused says "yes," find out when and where, if the request is recent
(i.e., fewer than 30 days ago),
obtain legal advice whether to ntinue the interrogation. If the suspect/accused says "no," or if the prior tuest was not recent, ask him/her the following question.)
lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a lawyer
present with you?"
(If the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on the other side of this form. If the suspect/accused says ''yes," have him/her read and sign the waiver section of the waiver certificate on the other side of this
form.)

SPECIAL INSTRUCTIONS
;EN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the
spect/accused orally waives his/her rights but refuses to sign the waiver tificate, you may proceed with the questioning. Make notations on the iver certificate to the effect that he/she has stated that he/she understands
her rights, does not want a lawyer, wants to discuss the offense(s) under
estigation, and refuses to sign the waiver certificate.

NAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases
waiver certificate must be completed as soon as possible. Every effort
)uid be made to complete the waiver certificate before any questioning
;ins. If the waiver certificate cannot be completed at once, as in the case of

ret interrogation, completion may be temporarily postponed. Notes should be
it
on the circumstances.
OR INCRIMINATING STATEMENTS:
If Me supsectiaccused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
•.4MENTS (Continued).
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper
rights advise!.
NOTE:

If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.
WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
interrogation, the suspect displays indecision about requesting counsel (for
example, "Maybe I should get a lawyer."), further questioning must cease
immediately. At that point, you may question the suspect/accused only
concerning whether he or she desires to waive counsel.
The questioning may not

be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you shouldn't need an attorney.")

6 3 C4

,./FRE OF DA FORM 3831
USAPA V2.01

DOD 002689

.t•t,

RICH, WARNiNG POfED ire
RURERIVANFR:CEP ,vi d
For use of this form, see AR 190-30; the proponent agency is ODCSOPS

DATA REQUIRED BY THE PRIVACY ACT
AUTHORITY:
Title 10,•VvitesIStates Code, Section 301 2(g)
PRINCIPAL PURPOSE:

To provide:#mmanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:
Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval. DISCLOSURE:
Disclosure of your Social Security Number is voluntary.
LOCATION 2. DATE . TIME FILE NO.
06 LiJc. it
/1J'R

NAME (Last, Firs!, 7v.//),v
8. ORG/A47 4TION OR ADDRESS
SSN
immiamms 11101111111111111111.11111.
7. GRADE/STATU
1.1111111111.

RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights
The investigator (.)
whose name appears below told me that he/she is with the United States Army )
t am
d wanted to question me, about the following offense(s) of which I am suspected/accused: I
1
fk. 4-1-9-7""t 11 0 .00--(CL-c---Pt 04.7 de."74-'qt
...(2

Before he/she asked me any questions about the offense s„ iloweve.r, h /she made it clear 2)me thatPhave the following rights:
1.
I do not have to answer any question or say anything.
2. Anything I say or do can be used as evidence against me in a' criminal trial.
3. (For personnel subject othe UCMJ
I have the right to talk privately to a lawyer before, during, and after questioning and to have a
lawyer present with me during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me, or both.
(For civilians not subject to the UCMJ/
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or
speak privately with a lawyer before answering further, even if I sign the waiver below.
COMMENTS (Continue on reverse side)
Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and withouthaving a lawyer present with me.
WITNESSES [If available) SIGNATUR OF INTERVIEWEE
NAME (Type or Print)

ORGANIZATION OR ADDRESS AND PHONE
TYPED NAME OF INVESTIGATOR
b.
6.

ORGANIZATION. OF INVESTIGATOR
Section C. Noaiver
n-w

I do not want to give up my rights
. I wani a lawyer 0 I do not want to be questioned or say anything
2.
SIGNATURE OF INTERVIEWEE
ATTACH THIS WAIVER CERTIFICATE TO ANY SWORN
STATEMENT (DA FORM 2823)

SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
ON

A
D FORM 3881, NOV 89 EDITION OF NOV 84 IS OBSOLETE • P, .01
DOD 002690

PART !I - RIGHTS WARNING PROCEDURE
THE WARNING

WARNING - Inform the'suspect/acctis.ea'•of:
a.
Your official position.

b.
Nature of offense(s).

c.
The fact that he/she is a suspect/abchsed

-

2.
RIGHTS - Advise the suspect/accused of his/)der rights as follows: "Before I ask you any questions, you must understand your rights."
a.
"You do not have to answer my questions-gr say anything."

b.
"Anything you'ray or'do can be used

e¦ride.nce against you in a
criminal trial:"

c. (For personneL subject to the UCMJ) "You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer
'i "Do you understand your rights?' (If the suspectiaccused says "no," determine what is not understood, and if
i necessary repeat the appropriate rights advisement. If the suspect/accused says
I "yes," ask the following question.)
1 "Have you ever requested a lawyer after being read your rights?"I )lf.the suspect/accused says "yes," find out when and where. If the request
was recent
(i.e., fewer than 30 days ago),

obtain legal advice whether to
continue the interrogation. If the suspect/accused says "no," or if the prior
request was not recent, ask him/her the following question.)

can be a civilian you arrange for at no expense to the Government or a military lawyer detailed for you at no expense to you, or both." -or -(For civilians not subject to the UCMJ)
You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins."
d.
"If you are now willing to discuss the offense(s) under investigation, with or without a lawyer present, you have a right to stop answering
questions at any time, or speak privately with a lawyer before
answering further, even if you sign a waiver certificate."

Make certain the suspect/accused fully understands his/her rights,
THE WAIVER
"Do you want a lawyer at this time?"
(If the suspect/accused says "yes," stop the questioning until he/she has a
lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a lawyer
present with you?"
(If the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on the other side of this form. If the suspect/accused says "yes," have him/her read
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the 1 suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning. Make notations on the waiver certificate to the effect that he/she has stated that he/she understands
1
his/her rights, does not want a lawyer, wants to discuss the offense(s) under I investigation, and refuses to sign the waiver certificate.
I
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning
begins. If
the waiver certificate cannot be completed at once, as in the case of street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
1. If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS (Continued)
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff
Judge Advocate should be contacted for assistance in drafting the proper rights advise!.
NOTE:

If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.
WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
interrogation, the suspect displays indecision about requesting counsel (for

example, "Maybe I should get a lawyer."), further questioning must cease immediately. At that point, you may question the suspect/accused only concerning whether he or she desires to waive counsel. The questioning may not be utilized to discourage a suspect/accused from exercising his/her rights. (For
example, do not make such comments as "If you didn't tic) anything wrong,
you

shouldn't need an attorney.")
63D

REVERSE OF DA FORM 3881
USAPA V2.01

DOD 002691

i;C:h ad.RN)NG PR.00EDURENVAIVER CEM :CA TE
t, V

For use of this form, see AR 190-30; the proponent agency is ODCSOPS
L.G.0

DATA REQUIRED BY THE PRIVACY ACT
AUTHORITY:
Title 10,-Mnited States Code, Section 3012(g)
PRINCIPAL PURPOSE:

To providS!'ociMmanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:
Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval-DISCLOSURE:
Disclosure of your Social Security Number is voluntary.
LOCATION
DATE 3. TIME FILE NO.

NAME (Last, First—M//
ORGATION OR ADDRESS
S

PART I - RIGHTS WAIVER/NON-WAIVER CERTIFICATE
Section A. Rights

The investigator whose name appears below told me that he/she is with the United States Arrriy
4-Fs (36c­
7-

I rand wanted to question me about the following offense(s) of which I am
suspected) accused: .(,--.

pceaccuse:
i ---71.9,---7)./1 4,74) 0--- Y" 110-1-d, ".tde_ ,-k-,4 )/
._-

1 Before he/she asked me any questions about the off ' ns (si, however he/she made it cl r.,)to me that I have the following righ
1.
I do not have to answer any question or say anything.
2.
Anything I say or do can be used as evidence against me in a criminal trial.
1
I
(For personnel subject othe UCMJ
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me
3.
during questioning. This lawyer can be a civilian lawyer I arrange for at no expense
to the Government or a military lawyer detailed for me at no expense to me, or both.
(For civilians not subject to the UCMJ) I
have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions
at any time, or speak privately with a lawyer before answering further, even if I sign the waiver below.
5. COMMENTS (Continue on reverse side)
Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking
having a lawyer present with me.

to a lawyer first and without
WITNESSES (If available) 3.

SIGNATURE OF INTERV EWEE
la. NAME (Type or Prim)
ORGANIZATION OR ADDRESS AND PHONE
4. SIGNATURE OF VESTrC TOR
a. NAME (Type or Print)
5. TYPED GATO
ORGANIZATION OR ADDRESS AND PHONE
6. ORG IZATION OF INVESTIGA 0
\„1

MII11111111•1111111
Section C. Non-waiver
1. I do not want to give up my rights
U I want a lawyer
0 I do not want to be questioned or say anything
2.
SIGNATURE OF INTERVIEWEE
630

I ATTACH THIS WAIVER CERTIFICATE TO ANY SWORN STATEMENT
(DA FORM 2823) SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
DA FORM 3881, NOV 89 EDITION OF NOV 84 IS OBSOLETE USAPA 2.01
DOD 002692

PART H - RIGHTS WARNING PROCEDURE
WARNING - Inform the suspect/ati?ed of:

a. Your official position.
b. Nature of offense(s).
c. The fact that he/she is a suspectieopused.

RIGHTS - Advise the suspect/accused of his/her rights as follows: "Before I ask you any questions, you must understand your rights."
a. "You do not have to answer my questions or say anything."

b. ­
Anything you say or do can be used'asevidence against you in a criminal trial.'

c. (For personfuliject to the UCMJ) "You have the right to talk privately tot lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer
;'Do you understand your rights?"
. (If the suspect/accused says "no," determine what is not understood, and if
necessary repeat the appropriate rights advisement. If the suspect/accused says yes," ask the following question.)
"Have you ever requested a lawyer after being read your rights?" If the suspect/accused says "yes," find out when and where. If the request was recent (i. e., fewer than 30 days ago),
obtain legal advice whether to continue the interrogation. If the suspect/accused says "no," or if the prior request was not recent, ask him/her the following question.)
THE WARNING
can be a civilian you arrange for at no expense to the Government or a military lawyer detailed for you at no expense to you, or both."
- Or -
(For civilians not subject to the UCMJ)

You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will
be appointed for you before any questioning begins."
g.
"If you are now willing to discuss the offense(s) under investigation, with or without a lawyer present, you have a right to stop answering
questions at any time, or speak privately with a lawyer before
answering further, even if you sign a waiver certificate."

Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you want a lawyer at this time?"
(If the suspect/accused says "yes," stop the questioning until he/she has a
lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a
statement without talking to a lawyer and without having a lawyer present with you?"
flf the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certifiCate on the other side of this form. II the suspect/accused says "yes," have him/her read and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning. Make notations on the
• waiver certificate to the effect that he/she has stated that he/she understands his/her rights, does not want a lawyer, wants to discuss the offense(s) under investigation, and refuses to sign the waiver'certificate.
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning
begins. If the waiver certificate cannot be completed at once, as in the case of street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
I . If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS (Continued)
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper
rights advisal.
NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section
on the waiver certificate and initialed by the suspect/accused.

WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR
HER RIGHTS DURING THE INTERROGATION PROCESS: If during the
interrogation, the 'suspect displays indecision about requesting counsel (for
example, "Maybe I should get a lawyer."), further questioning must cease
immediately. At that point, you may question the suspect/accused only
concerning whether he or she desires to waive counsel. The questioning may not be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you
shouldn't need an attorney.")
630 9

REVERSE OF DA FORM 3881
USAPA 1/2.01

DOD 002693

r-T:GHTLt?Rt-jr:7-TqiREI\IVANTR P.FRLIF, AT]-
For use of this form, see AR 190-30; the proponent agency is ODCSOPS
DATA REGUIRED BY THE PRIVACY ACT
NUTHORITY:
Title 10, UpOd'States Code, Section 3012(9)
'RINCIPAL PURPOSE:

To provide c.8:.:pinianders and law enforcement officials with means by which information may be accurately identified. tOUTINE USES:
Your Social Secofity Number is used as an additional/alternate means of identification to facilitate filing and retrieval. )ISCLOSURE:
Disclosure of your Social Security Number is voluntary.
LOCATION 3. TIME FILE NO.
C(-1.tHO TST--

( A It
1
0.-2)

NAME (Last First M
ORGANIZATION OR ADDRESS
PART I -RIGHTS WAIVER/NON -
;ection A. Rights
he investigator whose name appears below told me that he/she'is with the United States Army
1,0 4FStL,7i) L7-

t and wanted to question me about the following offense(s) of which I am
uspectedlaccused: titc:/ tjrt
(,-f /3 /A
of ore he/she asked me any questions about the offense(s), hoWie-Jer, he/she made it clear to me that I have the following rights:
I do not have to answer any question or say anything.

Anything I say or do can be used as evidence against me in a criminal trial.
(For personnel subject othe UCMJ I
have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me,
or both.
- or -
(For civilians not subject to the UCMJ)

I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer
present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with or without a lawyer present, I have a right to stop answering questions at any time, or
speak privately with a lawyer before answering further, even if I sign the waiver below.
COMMENTS (Continue on reverse side)
ection B. Waiver
understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without
suing a lawyer present with me.

WITNESSES (If available) SIGNATURE OF INTERVIEWEE
a. NAME (Type or Print)
ORGANIZATION OR ADDRESS AND PHONE
SI LIRE OF INVES IGAT
NAME (Type or Print)
5.
TYPED NAME OF INVESTIGATOR

6.
ORGANIZATION OF INVESTIGATOR

GANIZATION OR ADDRESS AND PHONE
ection C. Non -waiver
I do not want to give up my rights
. I want a lawyer . I do not want to be questioned or say anything
SIGNATURE OF INTERVIEWEE
TTACH THIS WAIVER CERTIFICATE TO ANY SWC N STATEMENT
(6 • FORM 2823) SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED FORM 3881, NOV 89t EDITION OF NOV 84 IS OBSOLETE USAPA 2.01
DOD 002694

?13,RT it- RIGHTS WARNING PROCEDURE
WARNING - Inform the ,suspectlaccUae
a. Your official position.
b. Nature of offense(s).
c. The fact that he/she is a suspect/a ccused :: -

RIGHTS - Advise the suspect/accused of his/her rights as follows: "Before I ask you any questions, you must understand your rights."
a.
"You do not have to answer my questions or say anything."

b.
"Anything you say or do can be used as"'evrdence aoainst you in a criminal trial..:'

c.
(For personnelltrbiect to the UCMJ) "You have the right to talk privately to a liwyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer

"Do you understand your rights?"
(If the suspect/accused says "no," determine what is not understood, and if

necessary repeat the appropriate rights advisement. If the suspect/accused says "yes," ask the following question.)
. "Have you ever requested a lawyer after being read your rights?" ilf the suspect/accused says "yes," find out when and where. If the request was recent li.e., fewer than 30 days ago),
obtain leol advice whether to
continue the interrogation. If the suspect/accused says "no,"

or if the prior
request was not recent, ask him/her the following question.)

THE WARNING
(

can be a civilian you arrange for at no expense to the Government or a military
lawyer detailed for you at no expense to you, or both."
- Or -
(For civilians not subject to the UCMJ)

You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins.".
h.
"If you are now willing to discuss the offense(s) under investigation,
with or without a lawyer present, you have a right to stop answering
questions at any time, or speak privately with a lawyer before
answering further, even if you sign a waiver certificate."

Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you want a lawyer at this time?"
I

(If the suspect/accused says "yes," stop the questioning until he/she has a
lawyer. If the suspect/accused says 'no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a lawyer
present with you?"
(If the suspect/accused says "no," stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on the other side of this form. If the suspect/accused says "yes," have him/her read and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning.
-Make notations on the waiver certificate to the effect that he/she has stated that he/she understands his/her rights, does not want a lawyer, wants to discuss the offense(s) under investigation, and refuses to sign the waiver certificate.
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases
the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of
street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
PRIOR INCRIMINATING STATEMENTS:
1 If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS (Continued)
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper
rights advisal.
NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.

WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR HER RIGHTS DURING THE INTERROGATION PROCESS: If during the interrogation, the suspect displays indecision about requesting counsel for example, "Maybe I should get a lawyer."), further questioning must cease immediately. At that point, you may question the suspect/accused only concerning whether he or she desires to waive counsel. The questioning may not
be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't . do anything wrong, you shouldn't need an attorney.")
6 3J

REVERSE OFDA FORM 3881
USAPA V2.01

DOD 002695

RIGH3_ WARNING­

PROCEDURE/WAIVER CESTIa —ATF
For use of this form, see

AR 190-30; the proponent agency is ODCSOPS
DATA REQUIRED BY THE PRIVACY ACT
.•

AUTHORITY:
Title 10, Lribited States Code, Section 30121g)

PRINCIPAL PURPOSE:
To providekornmanders and law enforcement officials with means by which information may be accurately identified.
ROUTINE USES:
Your Social SeOurity Number is used as an additional/alternate means or identification to facilitate filing and retrieval.
DISCLOSURE:
Disclosure of y3ur Social Security Number is voluntary.
A

LOCATION ''
2. DATE
1G TIME FILE NO.
-

(,-; /0 C
8. (Malt ATION OR ADDRESS
0 SSN
PART I - RIGHTS WAIVER/NON-WAIVER CERTIFICATE'
Section. A. Rights
The investigator whose name appears below told me that he/she is with the United States Army
and wanted to question me about the following offenses) of which I zmsuspecrediaccused:
'` ( ).
A I.c
Before he/she asked me any questions about the offense(s), ho r•
sjer, he/she €1:_tit clear to me that I ha j
h e followirg)ights:

1.
I do not have to answer any question or say anything.
2.
Anything I say or do can be used as evidence against me in a criminal trial.
3. (For personnel subject othe UCMJ
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me
during questioning, This lawyer can be a civilian lawyer I arrange for at no expense to the Government or a military lawyer detailed for me at no expense to me, or both.
-Or

(For civilians not subject to the UCMJ)
I have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with me during questioning. I understand that this lawyer can be one that I arrange for at my own expense, or if I cannot afford a lawyer and want one, a lawyer will be appointed for me before any questioning begins.
If I am now willing to discuss the offense(s) under investigation, with cr without a lawyer present, I have a right to stop answering questions at any time, or speak privately with a lawyer before answering further, even if I sign the waiver below.
5. COMMENTS
(Continue on reverse side)

Section B. Waiver
I understand my rights as stated above. I am now willing to discuss the offense(s) under investigation and make a statement without talking to a lawyer first and without
haying a lawyer present with me.
WITNESSES (If available)

SIGNATURE OF INTERVIEWEE
NAME (Type or Print) 3

ORGANIZATION OR ADDRESS AND PHONE 4. SIGNATURE OF INVESTIGATOR
2a. NAME (Type or Print)
TYPED NAME OF INVEST
ORGANIZAT OR A
ESS A D PHONE

ORGA ATION OF INVESTIGATOR
Section C. Non-waiver
I do not want to give up my rights
0 ! want a lawyer . I do not want to be questioned or say anything
2. ^ F
.4.TTAC' WAIVER CERTIFICATE TO ANY SWORN STATEMENT
WA FORM 2823)

SUBSEQUENTLY EXECUTED BY THE SUSPECT/ACCUSED
DA FORM 3881, NOV 89 4
EDITION OF NOV 34 IS OBSOLETE
USAPA 2.01

DOD 002696

PART H - RIGHTS WARNING PROCEDURE
WARNING - InforriVthe suspecti?:cc4sed of:
a. Your official position.
b. Nature of offense(s).
c. The fact that he/she is a suspectfacc.used.

RIGHTS - Advise the suspect/accused of„his/her rights as follows: "Before I ask you any questions, you must understand your rights."
a.
"You do not have to answer my questions or say anything."

b.

"Anything'you say or do can be used as evidence against you in a criminal. ria"
c. (For persdiii.e).sUbject to the UCMJ) "You have the right to talk privately to adawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer

"Do. you understand your rights?"
If the suspect/accused says "no,' determine what is not understood, and if

necessary repeat the appropriate rights advisement. If the suspect/accused says
"yes, -ask the following question.)

"Have you ever requested a lawyer after being read your rights?"
(If the suspect/accused says "yes," find out when and where. If the request
was recent (i.e., fewer than 30 days ago),

obtai,i legal advice whether to continue the interrogation. If the suspect/accused says "no," or if the prior request was not recent, ask him/her the following question.)
THE WARNING
can be a civilian you arrange for at no expense to the Government or a military I lawyer detailed for you at no expense to you, or both."
- Or -

li
(For civilians not subject to the UCM.JI
You have the right to talk privately to a lawyer before, during, and after questioning and to have a lawyer present with you during questioning. This lawyer can be one you arrange for at your own expense, or if you cannot afford a lawyer and want one, a lawyer will be appointed for you before any questioning begins."
d.
"If you are now willing to discuss the offense(s) under investigation
with or without a lawyer present, you have a right to stop answering
questions at any time, or speak privately with a lawyer before
answering further, even if you sign a waiver certificate."

Make certain the suspect/accused fully understands his/her rights.
THE WAIVER
"Do you want a lawyer at this time?"
(If the suspect/accused says "yes," stop the questioning until he/she has a
lawyer. If the suspect/accused says "no," ask him/her the following question.)
"At this time, are you willing to discuss the offense(s) under investigation and
make a statement without talking to a lawyer and without having a lawyer
present with you?"
(if the suspect/accused says "no,

stop the interview and have him/her read and sign the non-waiver section of the waiver certificate on
the other side of this form. /f the suspect/accused says "yes," have him/her read
and sign the waiver section of the waiver certificate on the other side of this form.)
SPECIAL INSTRUCTIONS
WHEN SUSPECT/ACCUSED REFUSES TO SIGN WAIVER CERTIFICATE: If the suspect/accused orally waives his/her rights but refuses to sign the waiver certificate, you may proceed with the questioning. Make notations on the waiver certificate to the effect that he/she has stated that he/she understands
his/her rights, does not want a lawyer, wants to discuss the offense(s) under
investigation, and refuses to sign the waiver certificate.
IF WAIVER CERTIFICATE CANNOT BE COMPLETED IMMEDIATELY: In all cases the waiver certificate must be completed as soon as possible. Every effort should be made to complete the waiver certificate before any questioning begins. If the waiver certificate cannot be completed at once, as in the case of
i street interrogation, completion may be temporarily postponed. Notes should be kept on the circumstances.
1 PRIOR INCRIMINATING STATEMENTS:
t
J 1, If the supsect/accused has made spontaneous incriminating statements before being properly advised of his/her rights he/she should be told that such statements do not obligate him/her to answer further questions.
COMMENTS (Continued)
2. If the suspect/accused was questioned as such either without being advised of his/her rights or some question exists as to the propriety of the first statement, the accused must be so advised. The office of the serving Staff Judge Advocate should be contacted for assistance in drafting the proper
rights advisal.
NOTE:
If 1 or 2 applies, the fact that the suspect/accused was advised accordingly should be noted in the comment section on the waiver certificate and initialed by the suspect/accused.

1.; WHEN SUSPECT/ACCUSED DISPLAYS INDECISION ON EXERCISING HIS OR HER RIGHTS DURING THE INTERROGATION PROCESS: If during the interrogation, the suspect displays indecision about requesting counsel (for example, "Maybe I should get a lawyer."), further questioning must cease immediately. At that point, you may question the suspect/accused only
concerning whether he or she desires to waive counsel The questioning may not
be utilized to discourage a suspect/accused from exercising his/her rights. (For example, do not make such comments as "If you didn't do anything wrong, you shouldn't need an attorney.")
REVERSE OF DA FORM 38881
USAPA V2.01

DOD 002697

•4 • • • •••,.. • •

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63.A

DOD 002698

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DOD 002699

D ofu. for-t seoAR .CND REPORT/CID ROI r-firnif1411nyestigaii9)1 .
F-1.F CF. I Vi NG ACTIVITY
.•
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(include Zip Code)..
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!"..) ,:-/NER• i OTHER L OCATION FROM -INHERE OBTAINED
TIME/DATE El OBTAINED 1tCDtr•: ( •-•

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63f6

DOD 002700

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FCITP,M2823, DECEC 19:98 • L 72 S OBSOLETE
DOD 002701

SWORN STATEMENT
P
\t1,

F6c use of this form, see AR 190-45; the proponent agency is ODCSOPS
•
PRIVACY ACT STATEMENT

•
'1!ii • (SSA).

f:tion 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943
AUTHORITY: Title 10 US.CSeiiTo provide Pomanders and law enforcement officials with means by which information may be accurately
PRINCIPAL PURPOSE:
te filing and retrieval.

Your social secukty number is used as an additional/alternate means of identification to fa
ROUTINE USES: Disclosure of your SYocial security number is voluntary.
DISCLOSURE:
1 3. TIME fill 4. FILE NUM. R

2. DATE (YY.YYMMDDs),2
1. LOCATION
5/
Z04)7
-r.AV
• :'1-­

Atf/r1:27c 7. GRADE/STATU
6. SEN
5. LAST NAME, FIRST N-iME, MIDDLE NAME
8. ORGANIZAT ON OR -ADDRESS
it----
•

WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH
I ,t ,
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I ITIAL OF PERSON MAKING STATEMENT
PAGES

10. EXHIBIT PAGE 1 OF
.TAKEN AT.DATED ADDITIONAL PAGES MUST CONTAIN THE HEADING 'STATEMENT
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER
MUST BE BE INDICATED.
6
154.3A
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DA FORM 2323, JUL 72, IS OBSOLETE
DA FORM 2823, DEC 1998 4.31 I Co)
DOD 002702

USE THIS PAGInl;`-NEEDED. IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED TO FINAL PAGE OF THIS FORM.
•

STATEMENT OF TAKEN AT :•-410 (3.DATED ;2.0 6) 3/0 d167-1
`
9. STATEMENT"viContinued)
1,1
6319

DOD 002703

STATEMENT OF i)
4111011111111.111111V •t
TAKEI AT L.-6,,,"
DATED 2 Oc)
9. STATEMENT (Continued);
.„-.

wa

AFFIDAVIT , HAVE READ OR HAVE HAD READ TO ME THIS STAT MENTWHICH BEGINS ON PAGE 1, AND ENDS ON PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEM NT MADE
BY ME. THE STATEMENT

IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH P GE
CONTAINING THE STATE

LENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHO T
THREAT OF PUNISHMENT

AND WITHOUT COERCION, UNLAWFUL INFLUENCE, R UNLAWFUL INDUCEMENT.
(Signature f Person Making Ste tern
WITNESSES:
d9

Subscribed and sworn to before me, a person authorized by law to administer oaths, this-1".7 day of
67 c 101)(,I, .57-, 2 C5f.:‘, at
ORGANIZATION OR ADDRESS
(Typed Name of Person A minis ering Sat
ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATEMENT
PAGE OF ---c PAGES

PAGE 3, DA FORM 2823, DEC 7998

6 3 toA
1 OG

DOD 002704

SWORN STATEMENT
0

.For.use of this form, see AR 190-45; the proponent agency is ODCSOPSLOCATION !DATE
C l E NUMBER
• ' ( gt.f4'02
LAST NAME FIRST NAMEMODLE NAMC
SOCIAL/SECURITY NUMBER

GRADE/STATUS ORGANIZATION 0 1 D 2 SS
WANT TO MAKE THE FOLLOWING STATEMENT UNDER OAT
Oh

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EXHIBIT •61,51
PERSON MAKING STATEME
PAGE 1 OF tPAGES

ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF • ---1AKEN AT .DATED.
CONTINUED." THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED
AS "PAGE.• OF. PAGES." WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 7 WILL SE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS FORM.
DA FORM 2823, JUL72t
SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED. USAPPC V2101 3 .[
0

DOD 002705
STATEMENT (Continuer!)
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AFFIDAVIT
, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENTWHICH BEGINS ON PAGE 1 AND ENDS ONPAGE cZ
. I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAciE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.
t L'
(Signature of Person Meking67tatement)

WITNESSES:
Subscribed and sworn to before me, a person authorized' by law to administer oaths, this tday of t at 0
ORGANIZATION OR ADDRESS
(Signature of Person A:iministering Oath)
ti
(Typed Name of Parson Administering ph)

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON rvlAKING STATEMENT
PAGES
US P V 2.00
)
44#

DOD 002706

I

SWORN. STATEMENT
For,use of this form, see AR 190-45; the proponent ency is OD SOP
LOCATION

DATE
(-CA-442p
L,.„4„,-,kors:...e

r)r-b:3 (. 1"
LA T NAME, FIRST NAME, MIDDLE A

SOCIAL SECURITY NUM
, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
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EXHIBIT
KING STATEMENT
yj 6-1 bictPAGE OF tO tPAGES

ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF
.TAKEN AT.DATED.

CONTINUED.".G 3 L,
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF
THE PERSON MAKING THE STATEMENT AND BE INITIALED I

AS "PAGE OF.
PAGES " WHE.N 'DDI-N

'OP PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE
DOD 002707
STATEMENT (Continued) •

9. ( I

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AFFIDAVIT
, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENTWHICH BEGINS ON PAG 1 AND ENDS ON PAGE
' . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE
BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAG
CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT
THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL I

I.
\9 192;LIL-LI
(Signature of Person Making Statement)

WITNESSES:
Subscribed and sworn to before me, a person authorized by law to administer oaths, thistet' da oft 1-9-t at
ORGANIZATION OR ADDRESS
(Signature of Person Admini.Pg Oath)
(Typed Name of Person Administering Oath)

ORGANIZATION OR ADDRESSt
(Authority To Administer Oaths)

.1 INITIALS OF PERSON
PAGE 7_ OF 7 PAGES

6s321°

DOD 002708
002708
1)*'¦ yt

1
3 SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is ODCSOPS
LOCATIONt• -.. • 3
. DATE
TIMEt
,-,

r-C--/-).t4..9 ' ' - - - ' ' 'c, )-. I FIL NUMBER ..j.40] O
-0
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LAST NAME, FIRST NAMP MIOF N AMP

SOCIAL SECURITYt ' GRADE/STATUS
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EXHIBIT
INITIALS OF PERSNt
G STATEMENT PAGE 1 OF t

ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF.TAKEN AT.DATED.
CONTINUED.
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE

1
AS "PAGE OF PAGES." WHEN ADoITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT,
STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS FORM.

DA FORM 2323, JUL 72
SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED, t USAPPC V2.00
632 5
11111110
DOD 002709

STATEMENT
(Continued)

7z (t
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Ncl`d
I,
t

,. HAVE READ OR HAVE HAD READ Ts ME THIS STATEMENTWHICH BEGINS ON PA 1 AND ENDS ON PAGE
"-...

. I FULLY UNDERSTAND THE CONTENTS OF THE TIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTT M OF EACH PAGE, ' CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR R ARD, WITHOUf THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL
tMENT.
Cu1 -TS0 Making tatement)

WITNESSES: Subscribed and sworn to before me, a pq son authorized by law to
administer oaths, this tday of t — t,
att -K"
ORGANIZATION OR ADDRESS
(Typed Name of Person Administering Oath)

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATEMENT
PAGE
9 OF ,t PAGES
USAPPC V2.00
632G

DOD 002710
SWORN STATEMENT
For use of this form, see AR 190-45; the prow
t agency is ODCSOPS
LOCATION

DATE ' TIME
„ee'r,
Ce-cvlorre , 0-0
(`-(t

LAST NAME, FIRST NAME, (ii1f:30LE 4iV1E , WANT TO2\ilAKE THE FOLLOWING STATEMENT UNDE,

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INITIALS OF PERSQAKING STATEMENT PAGE 1 OF tPAGE-
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF .TAKEN AT.DATED.CONTINUED."
THE
BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THF INITIALS OF THE PERSON MAKING THE STATEMENT AND BE
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AS "PAGE .OF.
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DA FORM 2823, JUL 72
SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED. USAPPC V2 00
634:7

DOD 002711

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t , HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT
WHICH BEGINS ON PAGE 1 AND E

ON PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE
BY ME. THE STATEMENT IS TRUE. I HA

IITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE
CONTAINING THE STATEMENT. I HAVE MADE

1
STATEMENT FREELY WIT HOPE OF FIT OR REWARD, WITHOUT
THREAT OF PUNISHMENT, AND WITHOUT COERCION, -N.LZWFUL INFLU

(Signature of Person Making Statement)

1 WITNESSES: Subscribed and sworn to before me, a person authorized by law to 7 CZ)
administer oaths, this tIS day of 1
,A("\--'-/.,

att • 0
/

ORGANIZATION OR ADDRESS
(Signature of Person.stering Oath
(Typed Name of Person Administering Oath)

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATEMENT
2.13

DOD 002712

SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is ODCSOPS
LOCKION"
I
DATE
I TIME

(..2, AtD Weci V)Or • .1 FILE NUMBER ILO l-CUCr 03.
LAST NAME, FIhST NAME; MIDDLE NAME I 5
I SOCIAL, peuFirry Nume5R
orip:Amz4:

, WANT TO W1AKE THE FOLLOWING STATEMENT UNDER OATH: I cI- 0 .OL--.00 kirc 4-1(Le Arl k),A 10---)
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04.cf . 6•_ • C Q (+a i
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EXHIBIT
INITIALS OF PERSONIN6'STATEMENT /

i PAGE 1 OF tZ---PAGES I ' ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT d...: • •
-: ,•ndif,EN AT.
DATED.CONTINUED."

THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED
AS "PAGE.OF.

1.
PAGES." WHEAI ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE
STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS FORM.

1 :
.
DA FORM 2823, JUL72t

SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED
USAPPC v2.00:4632o .
DOD 002713

STATEMENT
(Continuecti ,

AFFIDAVIT , HAVE READ OR HAVE HAD READ TO ME THIS STATEMENTWHICH BEGINS ON PAGE 1 AND END ON PAG
1 1,-
. I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADEBY ME. THE STATEMENT IS TRUE. I HAVE INI IALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PGECONTAINING THE STATEMENT. I HAVE MADE IS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT
' THREAT OF PUNISHMENT, AND WITHOUT COER tr
ION, UNLAWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.
No 'Mt A
(Signature of Person Making Stakrpent)
L1C

WITNESSES:
Subscribed and sworn to before me, a person authorized by law to administer oaths, this tle day of
„:47/Lec-a-A— t
at
2-20

ORGANI7ATION OR ADDRESS
(Signature of Person Admit?,

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

!INITIALS OF PERSON MAKING STATEMENT
PAGE Z. OF 7

DOD 002714
SWORN STATEMENT
For use of this 'form, see AR 190-45; the proponent agency is ODCSOPS

I LOCATION t
DATE TIME
FILE NUMBER

LiCurl.tV)4likOr5 e, , /b A o 3
LAST NAME, FIRST NAME, Mr&D,,,E NAME

SOCIAL`SECURITY NUMBER
GRADE/STAT

t111111111111111111111.
ORGANt• •E S
I,I

WANT TO MAKE THE FOLLOWING STATEMENT 1.11 DER OATH:
0)1 13A L4p',th/(c.

hvet7;74,, r 4.
I 1:t-
q e fti e.EP1 C/6 /ICt
e6r;.Cre41tcoi S't"LW
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/ •
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C..4 A.-.1./.f.
S2.o
•
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104 vt,N ptc.t‘A.,tFDt
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--V 7c.-
EXHIBIT
INITIALS OF PERSON MAKING STATEMENT PAGE 1 OF tPAGES
1110
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF .TAKEN AT.
DATED.CONTINUED."
THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF

THE PERSON MAKING THE STA TEMENT AND BE INITIALEDAS "PAGE.OF.

PAGES." WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE I WILL BE LINED OUT, AND THE
STATEMENT WILL BE CONCLUDED ON THE RE VERSE SIDE OF ANOTHER COPY OF THIS FORM.

DA FORM 2823, JUL 72t
SUPERSEDES DA FORM 2823, 1 JAN 58, WHICH WILL BE USED. USAPPC V2.00
6331

DOD 002715

STATEMENT (Continued)
,

d.6.
a..0(c7.

. ) IC .. i"ry M CAW.Cc, e.,
VC.1 Q;ISP (E ffir4 Is C -To t
r rt.C.01/ fc.)-46,45'01 Gt/erk-6el ntitA,2
11-A-i--(.14 kl.ft. C A--1/-.1.,/
140-v-U

sly pfp,tt s44 &r.
cic vi.il/t C..4 r- kv\-11-1

AFFIDAVIT
I,

-

HAVE READ OR HAVE HAD READ TO M .IS
STATEMENT
WHICH BEGINS ON AGE 1 AND ENDS
ON PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE ATEMENT MADE

BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF
CHPAGE

CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWAR
D, ITHc5UT

THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNL, F
(Sigtatare eking.tement)

WITNESSES:
Subscribed and sworn to before me, a person authorized by law to administer oaths, this ti(O''1---day of
,

at
ORGANIZATION OR ADDRESS
(Signature of Person o inisterinq Oath)
(Typed Name of Person ministering Oath)

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATEMENT
PAGE T._ OF -2 PAGES

USAPPC V2.00
YJ -j

6 3 ,s
t. 7C

DOD 002716

;,•

SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is ODCSOPS
LOCATION

TIME FILE NUMBER
I 70
LAST. NAME, FIRST NAME,I1IDDLE NAME
GRA /STATUS
ORGANIZAT
t
WANT TO MAKE THE FOLLOWING STATEMENT UND
R OATH:

-\Th \ ,r:j tLPio 5 a_k_t---crv._ 1 I tS 1 3 idL,LD
340-roi---' 't
pL2J.:Qz,A . -.-p Li) n

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iP7
EXHIBITt

INITIALS OERS0M4LGSTATEMENT PAGE 1 OF tPAGES
ADDITIOIVAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF .TAKEN AT.
DATED.CONTINUE THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE !MT/A LED AS "PAGE OF PAGES." WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, e1ND THE STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS FORM.
DA FORM 2823, JUL 72t
SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED. L1SAPPC '/2.00
6333

DOD 002717
STATEMENT (Continued)
i -
Is,
.,---..
a
-,
Q.2) ,,(31-4ThCA L-XlMCV

1 \ k
D-LLUrQ
11' --"Uer.,-)--;-1,--C-k--
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'
rt.•.-
\Dkt_A(N. /cL
JA.Q„yul.n/Lsj
t6.
CA_CLO--1-)
_
Le,r-r\r-

AFFIDAVIT
, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT
WHICH BEGINS ON PA E-) AND ENDS ON PAGE

FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED A
CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE
CONTAINING THE STATEMENT. I HAVE MADE THIS STAT

MENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOGIT
THREAT OF PUNISHMENT, AND WITHOUT COERCION, UN

AWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT. 17(1 '
C I
('igna% re oPqrson Making Statement)
Subscribed and sworn to before me, a person authorized by law to ,

/(4.—,74-at
administer oaths, this day of
1, 0-
ORGANIZATION OR ADDRESS
(Signature of Pe;son Administipg Oath)
(Typed Name of Person Administering Oath)
ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF .P SON MAI
STATEMENT
PAGE OF PAGES
..
6 nee

DOD 002718

SWORN STATEMENT
For use of thiS form, see AR 190-45; the proponent agency is ODCSOPS
LOCATION

1DATE TIME FILE NUivlB
LAW) W6-P42M S • I )6 KI) el 03 'ICAO R-,,-.s
LAST NAME, FIRST NAME, l';'IDDLE NAME SOCIAL SECURITY NU ER GRADEIS-

i

I 111.111.1111111111,_, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
WC.AI , 13tWc‘u co(lito, (Qoi, ,v1,2_,VCV t
rY1c1.) lToi 61(11
'

tOYtSS'i no Soltr" UOL
1"

(Tic v ihD "J -C vur 1.„4
,\ At• 1

(A) } It
rVOtItTr ci-ru
)4c,/ lar and i„);..q cp,r1 QV1

r,tI

1 ,ri lbuIC,Cf_ lA) AlcAtv u0kciStrtCO\ i\n qtCCA t1-11-U°AUcf
-t
0
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CAC\

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TPDV.

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L

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l-v ItIt' cca,c4tfe-,
c-c faiibt-9 1tCit
,tit• ckccturi o-n-•tIt 1..joyt
•re •v\,)t 00+t.-bt
•J

ke.1.1yec,t./t/06,c)t04j-c.r,ct (--/ KtktI 40 --t/Le_ cc 1-J -5 k-11077)
EXHIBIT
OF PERSON MAKING STATEMENT PAGE 1 OF tr) PA
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF .TAKEN AT.DATED.CONTINUED."
THE BOTTOM OF EACH ADDITIONAL PAGE MUST SEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND SE INITIALED AS "PAGE OF PAGES." WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL SEL INED OUT AND THE STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS FORM.
DA FORM 2823, JUL 72
SUPERSEDES DA. FORM 2823, 1 JAN 68, WHICH WILL BE USED. USAPPC V2.00
DOD 002719

STATEMENT
(Continued)
\
tuk:ve.
wet-

ar) 110(- tit
SirrAY1(.15

rc_c-e ) kfc, T, It1--k,r, --c 171,, (Jul-ft' ervou
fke_ atal,Ltti werl- loack y . e__t)- urvAVC-c-jA)-cet . rAjcilvjtCare Of
rvI.
. •

+yi c e.
/A.1

AFFIDAVIT
, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENTWHICH N PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADEBY ME. THE STATEMENT IS TRUE. I HAVE INITIAL D ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE
CONTAINING THE STATEMENT. I HAVE MADE THIS 4
STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT
THREAT OF PUNISHMENT, AND WITHOUT COERCIO .
, UNLAWFUL INFLUENCE, O. UNLAWFUL INDUCEMENT.

61( -1t
ature of Persil Making Statement)

WITNESSES:
Subscribed and sworn to before me, a erson authorized by law to i administer oaths, this t
(5' tday of t , 1.1.

at 0
1 2-#0
6)

ORGANIZATION OR ADDRESS
(Signs u
m s e.th)
(Typed Name of Person Administering

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

FC. •(4 -t-ST
INITIALS OF PERSON MAKING STATEMENT
PAGE 7 OF

DOD 002720

SWORN STATEMEr¦IT For use of tris form, see AR 190-45; the proponent agency is ODCSOPS
LOCATION
DATEt

TIME
•dr-

t t I Lc, C71)tk ©c
LAST NAME, FIRST NAME, MODLE NAME SOCIAL SECURITY NUMBER GRADE/STATUS

• 1— •

INIAMIIIIMI MOt
, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
C,:-\- c;.---": -.amt
,.A'•-cs-'' °h

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C\ tiJG
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EXHIBIT
INITIALS OF PERSON MAKING STATEMENT

It 1 PAGE 1 OF :PAG
ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF .TAKEN AT.DATED.CONTHE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF
AS "PAGE.OF. THE PERSON MAKING THE.STATEMENT TINUED.
E
AND BE "INITIALED

PAGES." WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL S
LINE OUT„4ND THE

STATEMENT WILL BE CONCLUDED ON THE REVERSE SIDE OF ANOTHER COPY OF THIS ,FORM.
DA, FORM 2822 : J 1 IL 77t
SUPERSEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED.
USAPPC V2.00
6337

DOD 002721

STATEMENT (Continued)
44_1•t(f)# 5t \t :,
\ c'
..,1=11111111116
AFFIDAVIT
, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENTWHICH BEGINS ON PAGE 1 AND ENDS ON PAGE t
.

I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADEBY ME. THE STATEMENT IS TRUE.
I

HAVE INI 'IALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE HIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT CO RCION, UNLANNFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.
46b—Li k9G
(Signature of Person Ma ing taternent)

WITNESSES:
Subscribed and sworn to before me, a person authorized by law to administer oaths, this t(0 -1--clay of ' t
, at
ORGANIZATION OR ADDRESS
(Signature of Person Administ
(Typed Name of Person Administering Oath)

ORGANIZATION OR ADDRESS
(Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATEMENT
I PAGE ‘7 N OFtPAGES
-
usaPpgigo 8

DOD 002722

.
AUTHORIZED FOR LOCAL REPRODUCTION

ED!CAL RECORD 1
I CHRONOLOGiCAL RECORD OF REDiCAL CARE _
DATEt
It

SVMPTON1S, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each entry)

7-0tv
cht
es­61f—,,/ CLCiV
' 2 0.\'474 6 - T Ot( z3 V.A1 /-) 1 /) , 17::17 .• fcat r• •7, 0 c r.6,t•
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717 M4 Mfr,t-e-/
(
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3PITAL OR MEDICAL FACILITY 1 STATUS DEPART.ISERVICE RECORDS MAINTAINED AT
I

;NSOR'S NAME SSNIID NO.
RELATIONSHIP TO SPONSOR

IENT'S IDENTIFICATION:t
(For typed or written entries, give: Name - last, first, middle; ID No
or SSN; Sex; REGISTER NO. WARD NO.
Dare of airtn; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6 -97) Prescribed by GSNICiV1R

• FIRMA (41 CFR) 201-9.202-1 USAPA V2.00
--r-'1"--C-i ' ' r•
63

DOD 002723