Citizen's Self-Arrest Form
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 and responsibility to make a citizen's arrest. If you commit a crime, it would be extremely helpful (and provide a savings of tax dollars) for you to perform a Citizen's Self-Arrest.
Instructions: Fill out this form, answering all questions completely.

Enter your full name:Nickname or ALIAS:
Enter your home street address:Home Phone #:
AC:
City:State:ZIP Code:
E-Mail Address:
Height:WT:Eyes:Hair:Race:Sex:
Indentifying Scars/Marks/Tatoos, if any:
State the 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 before questioning 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:
  1. Do not leave your house. If you are not home now, go home immediately.
  2. Put any firearms or other potential weapons out of reach.
  3. Remove your belt and shoelaces.
  4. If others are present in your house, send them away. You may, however, talk to yourself.
  5. You are not to allow yourself any visitors.
  6. Conjugal visits are not permitted.
  7. Consumption of alcohol or use of any other non-prescription drugs is not permitted.
  8. Do not try to escape from your home.
  9. If you do attempt an escape, use all reasonable force to stop yourself.
  10. Report any escape attempts promply, by phone, to the local police.
  11. Do not disturb any evidence present in your home.
  12. Remain in your home until the police arrive.

To insure your Citizen's Self-Arrest is received, mail a copy of this form to your local police department, in accordance with the following instructions:
  1. Print out this form.


  2. 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






  3. 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)


  4. If you do not have a printer, type or carefully draw a facimile 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




  5. Sign and date this form and mail it to your local police department. If you do not know the address of your local department, send it to this address:

    Detective Foster L White
    P.O. Box 226
    Notasulga, Al 36866
    Attention: Arrest-by-Mail

    You are authorized to make one trip to a mailbox for this purpose.

    If you live outside of my jurisdiction I will fax it to your local police department.
To make your self-arrest official, press this button:


To reset this form, press this button:



Any questions can be directed toward This address
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