Reference: ………………………………… Date of Offence:………………….
Full Name:…………………………………………………………………………………………….
Date of Birth: ………………………..
Occupation: …………………………………………
Address: ……………………………………………………………………………………………..
Telephone Number: ……………………………………………………………………………….
*I am willing to attend court to give evidence
*YES/NO
If you were required to attend Court, are there any dates during the next six months, which would be inconvenient?
(E.g. holiday, regular weekly or monthly commitments)
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In the event that it is necessary to interview you personally, where and at what time of day would it be convenient for a
police officer to call?
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If you can, please give the identity (name address and telephone number) of any person who witnessed the incident.
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Please give details of where you recorded details of this incident and in particular the vehicle involved.
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I can produce these details at court if required *YES/NO
Signature ……………………………………………
Date ………………………...
Name …………………………………………………
Process & Collisions Unit, 2nd Floor, Stevenage Police Station, Lytton Way, Stevenage, Hertfordshire, SG1 1HF
[email protected]
Witness Statement
(Criminal Procedure Rules 2005, r.27.1(1);CJ Act 1967, s.9 & MC Act 1980, ss.5A(3)(a) & 5B)
FULL NAME: .................................................................................................................................................................
This statement (consisting of 4 pages each separately signed by me) is true to the best of my knowledge and belief and I
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 I know to be false or do not believe to be true.
Dated the
day of
in the year
Signed:……………………………………………………………………………………….........................................................
1.
State the time ................... am/pm day ................................. date ........................................... and location,
where the accident/incident occurred:
...........................................................................................................................................................................
2.
Describe, if appropriate, the vehicle you were in or on and your method of travel at the time, e.g. vehicle
driver, or passenger (say which seat you occupied), pillion passenger, pedestrian, pedal cyclist.
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3.
At the time of the incident/accident where were you, or where was the vehicle you were in or on?
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4.
State if you actually saw or heard the accident or witnessed the incident:
...........................................................................................................................................................................
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5.
Describe
(a)
The traffic volume, e.g. heavy, medium, light, very light:
.........................................................................................................................................
(b)
The weather conditions, e.g. fine, bright sun, cloudy, bright, dull, raining, snowing etc.:
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(c)
The road conditions, e.g. dry, wet, greasy, icy, snow covered etc.:
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(d)
The visibility, e.g. clear daylight, fog, dusk, dark etc.:
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(e)
If dark, state whether there was good, poor or no street lighting:
.........................................................................................................................................
Signed: ..................................................................................
Process & Collisions Unit, 2nd Floor, Stevenage Police Station, Lytton Way, Stevenage, Hertfordshire, SG1 1HF
[email protected]
6.
Describe each vehicle (make, model and colour) involved in the accident or incident and state its position,
direction of travel and approximate speed at the time of the accident or incident.
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7.
State whether you recorded the registration number of a vehicle (give the number) or whether this was
recorded by someone else and passed to you. If the latter, give the name and address of the person who
gave you the note. Say who has the note now and (if you have it) that you will be able to keep it safely and
produce it if required.
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8.
Describe in your own words exactly how the accident/incident happened.
STATE ONLY WHAT YOU SAW OR HEARD YOURSELF. IF THE ACCIDENT/INCIDENT OCCURRED TO
YOUR VEHICLE IN YOUR ABSENCE, PLEASE STATE WHAT YOU FOUND ON YOUR RETURN.
Include in the description whether:a)
b)
c)
d)
e)
f)
g)
Any signals were given by the driver(s)
The horn was sounded
Headlights or sidelights were on
‘L’ plates were displayed and the driver accompanied
occurred)
Any traffic sign or traffic light was obeyed or disobeyed
Any works or parked vehicles were in the vicinity
There were any injuries to persons
Please describe:
h)
Any damage to vehicles
(if it assists draw a diagram of the
vehicle indicating where damage
Please describe:
i)
Any damage to roadside property (e.g.
railings, lamp posts)
. ...........................................................................................................................................................................
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Signed: ..................................................................................
Process & Collisions Unit, 2nd Floor, Stevenage Police Station, Lytton Way, Stevenage, Hertfordshire, SG1 1HF
[email protected]
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Signed: ..................................................................................
9.
If any driver failed to stop, give the reasons why you believe he knew he had been involved in the
accident/incident, e.g. was the noise of the collision inaudible/clear/loud/very loud. Did he stop. Did he look
back. Did he speak to anyone at the scene:............................................................................................................................................................................
............................................................................................................................................................................
10.
State whether the police attended the scene of the accident/incident while you were there and if so whether
any vehicle was moved before they arrived.
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11.
Describe briefly each driver and say if you know them or would be able to recognise them, and how:............................................................................................................................................................................
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12.
If there was any conversation between you and any other driver involved, please give the exact words used,
and say which vehicle the driver was from:............................................................................................................................................................................
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Signed: ..................................................................................
Process & Collisions Unit, 2nd Floor, Stevenage Police Station, Lytton Way, Stevenage, Hertfordshire, SG1 1HF
[email protected]
13.
Please draw a sketch plan of the scene of the accident in the space below:-
14.
Do you drive a motor vehicle yourself? If so, state how long and with what experience:............................................................................................................................................................................
............................................................................................................................................................................
Signed: ..................................................................................
Process & Collisions Unit, 2nd Floor, Stevenage Police Station, Lytton Way, Stevenage, Hertfordshire, SG1 1HF
[email protected]