Incident Sworn Statement Template
Chronological format for an incident or event. Record only facts you know and identify second-hand information separately.

Declarant & Incident Details
Declarant name: _________________________________
Incident date: __________________  Time: _________
Location: _______________________________________
Reference / claim / case number: _________________

People Involved
Person 1 / role: __________________________________
Person 2 / role: __________________________________
Other witnesses: __________________________________

Chronological Account
1. What happened immediately before the incident:
_______________________________________________________________
2. What I personally saw, heard or experienced:
_______________________________________________________________
3. What happened next:
_______________________________________________________________
4. Actions I personally took:
_______________________________________________________________

Evidence / Supporting Material
Photos / video: _______________________________________________
Messages / emails / logs: ______________________________________
Reports / receipts / other records: _____________________________

Information From Others
Identify the person or source rather than presenting second-hand information as firsthand fact.
_______________________________________________________________

Sworn Confirmation & Signature
Required oath / affirmation wording: ____________________________
Declarant signature: _______________________  Date: _____________
Witness / notary / authorized official: _________________________