Instructions for Completing the Voluntary Statement Form

Instructions for filling out the Voluntary Statement Form

  1. DO NOT enter any information into the top box.
  2. Completely fill in the second box.
    • Form must include a VALID mailing address in order to send documents, should the incident go forward to prosecution.
    • Form must include a VALID telephone number to conduct any follow up that may be needed.
  3. Write a detailed description of the incident. Include the Who, What, When, Why, Where and How.
  4. Sign the form on the signature line.
  5. If additional room is needed, use the Statement Continuation Page or regular lined paper. Be sure to number and sign all additional pages.
  6. Return the form physcially or by mail mail the form to:
    Pershing County Sheriff's Office
    ATTN: Undersheriff Thom Bjerke
    P.O. Box 147
    Lovelock, NV 89419
    Or fax the completed form to (775) 273-5052, attention to Undersheriff Thom Bjerke.

The statement will be disseminated to a Deputy for investigation. Please allow a reasonable amount of time for a Deputy to contact you.