Before the Office of the Inspector General
United States Department of Agriculture

In RE:  Investigation of Forest Service		Case Number  KC899-0025
	  Law Enforcement Officers			Statement of Witness:

1.	My name is ......................................................
	My address is ......................................................
	I can be reached by telephone at  ......................................................

2.      ** ** 

__.   ..................

__.   ..............

__.   ..........

__.   .......

__.   ....

__.   Please acknowledge receipt of this statement and that it has been entered in the case record.

__.   I declare under the penalties of perjury pursuant to 28 U.S.C. 1746 that the above statements are true.

      Affirmed:  __________________________________		_______________
		[Name...							Date

 {Notary Statement -optional}

Simple Instructions, Batteries Not Included:

	This downloadable 'OIG-Rainbow' Statement Form is set up to serve as a page for handwritten statements OR an outline for a computer document, open to ¢hanges, deletions & Expansions to make it work with your words.
Print out a clean document when you're done (leaving THIS page out;-).

--  The formal header is recommended, because it is a formal proceeding.
-- "In RE:" might reference 'Rainbow Gathering...' as well... this is flexible.

1.	Start by stating name, address, and phone contact, email if you wish:  	This affirms your identity and makes the info handy, all at once.

2.	** ** {{Begin your statement on the incident(s) here....  

		Give a simple chronological account in short numbered paragraphs.  
State the location, date & time, what you were doing there, and what occurred – 
with careful details on actions & statements made; provide names, agencies,
& badge numbers of the officials involved.  
		Try to be clear & specific on the identities of individual officers... 
contact us for assistance if you need help identifying those involved.
		Include the impact of the incident on you personally, and how it affects 
your willingness & ability to attend such gatherings in the future.
		Say what YOU know or observed... hard facts matter most, reports from 
known sources can be noted, but unconfirmed hearsay is not useful.
__
__	} Two closing paragraphs:  It's a good idea to confirm that your statement was received by OIG and entered into the case record... 
THEN, affirm that you are telling the truth, and your signature is real.
With the 28 USC 1746 oath, using a Notary is optional, but still advised.

	SEND STATEMENTS TO THESE ADDRESSES:

Originals-	attn:  William Busby, Asst. Special Agent In-Charge
Submittal:	USDA Office of Inspector General -- Investigations
		12136 W. Bayaud Ave. - Ste. 210
		Lakewood, CO 80228
						{OR}	eM:  <wrbusby@oig.usda.gov>

Copies-	Don Wirtshafter, Attorney	
to Files:	PO Box 18 (7002 State Rte. 329)
		Guysville, OH 43735
							eM:  <don@hempery.com>

Support:	Scott Addison, Research
		PCU_/Free Assembly Project
							eM:  <pcu@free-assembly.org>