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RESTRICTED

Criminal Procedure

Statement of: ,
if under 18:

(when complete)

s.9;

r 27.2; Crimina! Justice Act

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b.' ..l.tg ....""""
18
18?
(ifover

insert 'over

"

MG11

agistr:ates' Courts Act 1980, 5.513

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Occupation:."

page(s) each signed by me) is true to the best of my knowledge and belief and
This statement (consisting of
make it knowing that, if it is tendered in evidence, I shall be liable to prosecution if I have wilfully stated in it,
anything which know to be false, or do not believe to be true.

QI

Oote ...
Tick if

5/2013 ]

RESTRICTED (when complete)

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