SELF ARREST FORM

 SELF ARREST FORM 

 

A proposition has been announced recently to help reduce the deficit and to “Take A Bite Out Of Crime.”  If you witness a crime, it is your civic duty to report the crime to the police.  When a crime is committed, you have the right to make a “Citizen’s Arrest”.  Thus, if YOU commit a crime, it would be extremely helpful for you to perform a Citizen’s Self-Arrest.  Fill out the form, to complete your Citizen’s Self-Arrest.

Fill out this form, answering all questions completely.

 

 

Enter your full name:

ALIAS:

 

 

 

 

 

 

 

 

Enter your street address:

Phone #:

 

 

-

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

 

 

E-Mail Address:

 

Height:

WT:

Eyes:

Hair:

Race:

Sex:

 

 

 

 

 

 

 

 

 

 

 Scars/Tattoos, if any:

 

 

 

 

 

CRIME for which you are arresting yourself:

 

 

 

 

 

PLEA:

Motive:

If Other, specify:

 

 

 

                           

 

Read the following statement aloud:

“I am under arrest. I have a right to remain silent. Anything I say can and will be used against me in a court of law. I have the right to talk to a lawyer and have him/her present with me while I question myself. If I cannot afford to hire a lawyer, one will be appointed to represent me, if I wish one, before I question myself. If I decide to make a statement, I may stop at any time.”

WAIVER:

Do I understand each of these rights I have just read to myself?
Yes No

Having these rights in mind, do I wish to talk to myself now?
Yes No
(If YES to both, use the space below for your full confession or other statement you may wish to make.)


STATEMENT/CONFESSION:

Memorize the following rules:

  • Do not leave your house. If you are not home now, go home immediately.
     
  • Put any firearms or other potential weapons out of reach.
     
  • Remove your belt and shoelaces.
     
  • If others are present in your house, send them away. You may, however, talk to yourself.
     
  • You are not to allow yourself any visitors.
     
  • Conjugal visits are not permitted.
     
  • Consumption of alcohol or use of any other non-prescription drugs is not permitted.
  • Do not try to escape from your home.
     
  • If you do attempt an escape, use all reasonable force to stop yourself.
     
  • Report any escape attempts promptly, by phone, to the local police.
     
  • Do not disturb any evidence present in your home.
     
  • Remain in your home until the police arrive.

 

To ensure your Citizen’s Self-Arrest is received, mail a copy of this form to your local police department, in accordance with the following instructions:

  • Print out this form.
  • Using a stamp-pad or ink-soaked sponge/tissue, provide a preliminary set of fingerprints on the printed copy of the form:

 

Right
Thumb 

 

 

Left
Thumb

 

 

Right
Forefinger

 

 

Left
Forefinger

 

 

  • If you have a recent passport-size photograph, enclose it with this form. If you do not have a photo but do possess some artistic skill, do a rough sketch of your appearance on a separate sheet of paper. (Do NOT sketch yourself wearing dark glasses. Do not add a beard or mustache if you do not normally have one)
  • If you do not have a printer, type or carefully draw a facsimile of this form on a blank piece of paper and fill in the appropriate information. Submission of a neat and complete form will be pointed out favorably to the DA’s office.

Signature of Arrestor/Arrestee
(required for mail-arrests only)

Date

  • Sign and date this form and mail it to your local police department.
    You are authorized to make one trip to a mailbox for this purpose.

 

The small patch below contains a remarkable offshoot of military technology:  An entire miniature Bible, produced by laser microprinting.  Place your left hand on the spot and raise your right hand and say “I swear that all of the information I have given on this form is true, so help me, God.”

XXXXX
XXXXX <—- (Bible)
XXXXX
XXXXX

 

To make your self-arrest official, press this button:

 

 

 

 

 
   

BETTS & ASOCIATES

16015 HEMLOCK DR.

NEWALLA, OK 74857

(405) 326-6503