(9) Your identification (duty title) and the office you represent. (FOR example, Military Police
Investigation, Provost Marshal's Office.)
(10) Offense or crime that the suspect or accused is believed to have committed. Use the term
or wording from the UCMJ; if the act was to steal a radio, enter "Larceny" or larceny of private property.
After the offense listed from the UCMJ, place three (3) slash marks (///).
After the offense is listed make sure the interviewee reads the rest of the statements in
(11) Comment: Comments will be filled out when anything unusual occurs while filling out the
form or while advising the suspect/accused of their rights (example: a refusal to sign or claim that the
suspect/accused does not understand the rights warning, or suspect states that he waived his right but
refused to sign the form).
(12) Signature of Interviewee: If the suspect/accused understood their rights and is willing to be
questioned about the offense(s), have them sign. If they waive their rights, but refuse to sign the
waiver, proceed with questioning after noting on the certificate that they:
Understand their rights.
Do not want a lawyer.
Refused to sign.
(13) Signature of Investigator: Sign your name.
(14) Typed name of Investigator: Type or print your first name, middle initial, last name.
(15) Investigator's Organization: Type or print the unit to which you are assigned. Include post,
state, and zip code.
(16) Signature of Witnesses: This is the person who witnessed the rights warning and the
completion of the form. Your partner will probably be the witness. Have him or her sign the form.
Enter the witness' name, address or organization, and telephone number on the two lines below the
word "WITNESSES." Always make an attempt to have a witness present during the rights warning
If the suspect/accused requests a lawyer or does not want to be questioned or say anything, have them
check the appropriate block.