RESTRICTED {when complete)            Fᵒʳᵐ MG¹¹

WITNESS STATEMENT

(CJ Act 1967, s.9; MC A ct 1980, ss.5A(3)(a) and 5B; C rim inal Procedure Rules 2005, Rule 27.1)
A                                  URN

Statem ent of.  LQ.                             ...™.  .  .  .  ......... —

Age if under 18..,.,,...... ........ ...... (if overf8 insert 'over 18‘)    Occupation,...        
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This statem ent (consisting o f ..... ............... page(s) each signed by m e) is true to the 
best of m y know ledge
and belief and I make it know ing that, if it is tendered in evidence, I shall be liable to 
prosecution if I have w ilfu lly
stated in it anything w h ich I know to be false or do not believe to be true.

Signature                                Date

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