Non-Consent Statement - Jackson County, WI

Case Number

Individual Information

Address Information *

NON CONSENT STATEMENT

I have given no permission to any person(s), specifically, *

To: (Check all that apply) Cause me injury or bodily harm
Cause damage to any property owned by me, in my possession, or, that I am responsible for
Take, use, conceal, or retain possession of any property, owned by me, in my possession, or, that I am responsible for
Enter or remain on any land of which I am the Owner
Enter or remain on any land of which I am the Occupant
Enter or remain on any land after receiving notice not to enter or remain on the land.
Enter or remain in any dwelling of which I am the owner
Enter or remain in any dwelling of which I am the occupant
Enter or remain in any dwelling of which I am lawfully on the premises, and, having at least equal rights to use and occupancy as the owner/occupant.

Describe: (Injuries, property, damage) in this field *

Dollar value of loss (if applicable)

Name of Insurance Company

I am capable of denying consent in this matter, by reason that I: *

Title (if applicable)

I understand that an arrest or other legal action may result against some person(s) based on my statement. I declare the information in this statement to be true and correct. I will appear as a witness in a court of law to testify in this matter, if needed.

Date *

Time

Signed

Officer

* - denotes required field