PerFORM Communicator File Packet v 1.00 @_c:\formflow\forms\AO5'>OA&6'>W>l6'>Cq-8:'>a2823.frow\forms\a2823.fro5? a2823.fdb\temp\df000000\a2823.fdb6R a2823.dbf\temp\df000000\a2823.dbf6R% % $a2823.dbt\temp\df000000\a2823.dbt6Ra2823.fds\temp\df000000\a2823.fds6RDA Form 2823, NOV 2006APD175C:\DOCUME~1\SHERMA~1\MYDOCU~1\ETM'S\FORMPA~1\2823.FPKC:\WINDOWS\TEMP\KDA Form 2823, NOV 200600 0?0"x 3,3"3 3n@3*Q3|;ࡱ> Root EntryRoot Entry` )HPTk wContents|OccDataInTempoWorkflow   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZSummaryInformation((FBMacrosPTk wPTk wGeneralMacroStream(_f\7BZ'Oh+'0y(   $ 0 <HPXP(d(l(DA Form 2823, NOV 2006APDSworn Statement175@*$@s@ JW;@Gh wG&48D1 X   "2 - !// !// !/ !/- -000--.- "Univers ww 0w f--- 2 5mTHE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER     -- %2 5MUST BE INDICATED. -.- -- Z2 57ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF   -%000`0`00-.- "Univers ww 0w f-- 2 DTSWORN STATEMENT     --  2 T "Universe Pww 0w f-- j2 TBFor use of this form, see AR 190-45; the proponent agency is PMG.    -%SSS-.- -- 2 X PAGE 1 OF -%]]-.- -- 2 3. TIME - -%]]00-.- -- 2 6. SSNE- -%ccc-.- -- 2 h 2. DATE -- 2  (YYYYMMDD) ---.- --  2 oMI, -Y-.- -- <2 A#DA FORM 2823, DEC 1998, IS OBSOLETE  -%000P0P00-.- -- 02 ;58. ORGANIZATION OR ADDRESS1- -%0FF00-.- -- 2 5 10. EXHIBIT- -%FSSFF-.- -- C2 S(11. INITIALS OF PERSON MAKING STATEMENT  - -0!-.- -- (2 3DA FORM 2823, NOV 2006      -%0cc00-.- -- 2 5 1. LOCATION- -%00000-.- -- @2 5&5. LAST NAME, FIRST NAME, MIDDLE NAME    - -%]]]-.- -- 2 b4. FILE NUMBER - -%]0]0]-.- -- 2 b7. GRADE/STATUS- -pVp- ---.- -- R2 o2, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:     --.- -- 2 PAGES-.- -- 2 "DATED-.- -- 2 TAKEN AT - - -Qn-.- --  2 \59.-.- "Univers ww 0w f--- '2 lRPRIVACY ACT STATEMENT --.- "Univers# ww 0w f--- 2 |5 AUTHORITY: --.- --- $2 5PRINCIPAL PURPOSE: N--.- --- 2 5ROUTINE USES: S--.- --- 2 5 DISCLOSURE: --.- "Univers ww 0w f- - 2 |]Title 10, USC Section 301; Title 5, USC Section 2951; E.O. 9397 Social Security Number (SSN). -.- - - 2 uTo document potential criminal activity involving the U.S. Army, and to allow Army officials to maintain discipline,    - - g2 @law and order through investigation of complaints and incidents.  -.- - - 2 nInformation provided may be further disclosed to federal, state, local, and foreign government law enforcement    - - 2 uagencies, prosecutors, courts, child protective services, victims, witnesses, the Department of Veterans Affairs, and   - - 2 nthe Office of Personnel Management. Information provided may be used for determinations regarding judicial or    - - 2 pnon-judicial punishment, other administrative disciplinary actions, security clearances, recruitment, retention,  - - B2 'placement, and other personnel actions. -.- - - ^2 :Disclosure of your SSN and other information is voluntary.  - !_0 - !0 - !0-.- "Univers Gww 0w f- - 2  APD V1.00WOWWOWWOWWOWWOWWOWWOWWOWWOWWOWWOWWOW FormFlow4 14 14 1400/00+ 1/30a  9 1/3  a  9 9: 9:144 9:14a 14 14 14 FormFlow 2.06PEPEO5O5 STATECONTCONTINUED @. ENDPAGE@. PG_NUM@. %TOTAL_PGES@. &THIS_DAY @. MONTHSWORN @. ADMIN_OATHISTER @. <"AUTHORITYO ADMIN @. <#PLACESWORN @. < WITNESS_A @. <WITNESS_BON @. <YEARK@. W8W82W82W8LOCATION @. <NAME @. <ORGANIZAION @. xFILENO @. GRADE @. EXHIBIT @. < PAGES@,  I_NAME_A @. <SSNult @. ڣW8ڣW8W8W8--TIMElt @. DATElt @. W8W8*W8*W8//I_NAME_B @. <SIGN_BMIN @. <!SIGN_AWORN @. <STATEMENT @.  STMTCONT @. STMTOFe @. 2 TAKENATe @. DATEDte @. p/O5p/O5/O5/O5//PAGE_A@. PAGE_BGES@. STMTOF_A @. 2TAKENAT_A @. DATED_Ae @. 3O53O54O54O5//INITIALS @.  INITIALS_A @. INITIALS_C @. $dBASECourier1Univers (WN)"CG Times (WN)Times New RomanModern2Times New RomanMS Sans Serif"Arial"Arial MT"Arial"Univers (E1)"CG Times (E1)CG Times (W1)Univers (W1)"RomanCG TimesUnivers"Verdana"Ya $ϵ\KhC?=?oШSg/?8 PgЈ/< Gz7/OGG?Vt7?ro0 7t7r07n77W8A282O+t777RWV718cԔp )D[()\KhC\KhC\KhC&11.C3(N11C(1  STATEMENT  1).C NX 333333 THE BOTTOM OF EACH ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT, AND PAGE NUMBER MUST BE INDICATED. 1 C< X t=O5;L<3t=O5L<3ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF116cC3(u0X  8>O5].O58>O5.O5SWORN STATEMENT For use of this form, see AR 190-45; the proponent agency is PMG. (g 9(1X ?O5TD3?O5TD3PAGE 1 OF q=Fi0  TIME W8zO5W8zO5 3. TIME ̖q0:!iF0  SSN W8*O5W8*O5 6. SSN SEo =i0  DATE @O5#ڠO5@O5ڠO5 2. DATE  (YYYYMMDD) tEkLYT|]x |AO5O5|AO5O5I,.l`N?d1X BO5'r3BO5r3DA FORM 2823, DEC 1998, IS OBSOLETE10:B[C(0  ORGANIZAION CO5 bO5CO5bO5 8. ORGANIZATION OR ADDRESS 1XQ C1XX  EXHIBIT DO5L3DO5L3 10. EXHIBIT XQ(g 91XX  INITIALS DO5-S3DO5S3 11. INITIALS OF PERSON MAKING STATEMENT 1.)CNd1X  EO5z3EO5z3DA FORM 2823, NOV 20061 oC=i0  LOCATION 8GO54O58GO54O5 1. LOCATION 1̖0:Ci!0  NAME HO5+O5HO5O5 5. LAST NAME, FIRST NAME, MIDDLE NAME q F=(i0  FILENO IO5O5IO5O5 4. FILE NUMBER q0:Fi(0  GRADE JO5O5JO5O5 7. GRADE/STATUS LYkT|x0  I_NAME_A   įF1X  PAGES   kT|( >LO56FO5>LO5FO5, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:8 (1X  LO5[3LO5[3PAGES+ <]+ X MO5Xc3MO5Xc3DATEDh  d X ,NO5 k3,NO5 k3TAKEN ATh/ d  +  dW5 ] 1B[`OkCj ~OO5DO5~OO5DO59.16csCu( PO5#O5PO5O5PRIVACY ACT STATEMENT1sHC tQO5O5tQO5O5AUTHORITY: GY!W?&o477?Ͷ 7tQO5Δ7V!7GY!W?&o477?Ͷ 1HєC RO5"O5RO5O5PRINCIPAL PURPOSE:  1]C RO5hO5RO5hO5ROUTINE USES: 1 C'= fSO53fSO53DISCLOSURE: sH(  TO5a3 TO53Title 10, USC Section 301; Title 5, USC Section 2951; E.O. 9397 Social Security Number (SSN).H\( TO53TO53To document potential criminal activity involving the U.S. Army, and to allow Army officials to maintain discipline, law and order through investigation of complaints and incidents.] (= 6VO5O56VO5O5Information provided may be further disclosed to federal, state, local, and foreign government law enforcement agencies, prosecutors, courts, child protective services, victims, witnesses, the Department of Veterans Affairs, and the Office of Personnel Management. Information provided may be used for determinations regarding judicial or non-judicial punishment, other administrative disciplinary actions, security clearances, recruitment, retention, placement, and other personnel actions. '(= XO5>*3XO5*3Disclosure of your SSN and other information is voluntary.16c6cCu(u1  C=(=1  C(t.N(d .ZO5b3.ZO5b3APD V1.00111-CB(^11.)C^t0X [O5[O5DA FORM 2823, NOV 20061dI.C2^0X  INITIALS_A [O5([O5 INITIALS OF PERSON MAKING STATEMENT 1єC(21  STMTCONT \O5)\O5 9. STATEMENT (Continued) 16cԔsCX ]O5]O5STATEMENT OFx?6csaX H^O5H^O5DATEDy6c|sWX ^O5^O5TAKEN ATԔ6cys1  STMTOF  |6cx?sW1  TAKENAT  q6csF1  DATED  11RCB(o1 aO5paO5USE THIS PAGE IF NEEDED. IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED TO FINAL PAGE OF THIS FORM. dI.2(^0 bO5bO5PAGE{Ę.S2{^0   PAGE_A  L.2^0   PAGE_BGES  L.2(^0  "eO5"eO5PAGESĘ.{2^0 lfO5lfO5OFGY!W?&o477?Ͷ 7lfO5Δ7V!7GY!W?&o477?Ͷ h/g} gO55gO5, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT11.C3(N1X16c߄Cu(P1X  STATECONTCONTINUED ThO5/ThO5 9. STATEMENT  (Continued)  `9*8:.D  iO5 iO5, :KKID Z1  PLACESWORN iO5iO5 :|KK<DWZ jO5jO5at er oathss;hPg kO51kO5 BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.dI."(N1 lO5lO5PAGE9*I. pmO5DpmO5Subscribed and sworn to before me, a person authorized by law to  I 1