STATE OF [State]

COUNTY OF [County]

I, [Affiant Name], being duly sworn, depose and state:

Background Information

Residence:                                                                                                                      

Occupation:                                                                                                                    

I am over the age of eighteen years and have direct knowledge relevant to the incident described below. I am not a party to the case but an observer of the incident.

Description of the Incident

On the day in question, at approximately [Time], I was located at [Location of the Incident].

I observed the following:

• A vehicle was traveling at what appeared to be a speed exceeding the posted limit. The vehicle collided with a pedestrian crossing the intersection at [Specific Intersection].
  

• The pedestrian, who had the right of way as indicated by the pedestrian crossing light, was struck on their right side and fell to the ground.
  

• Immediately following the impact, the driver of the vehicle stopped, exited the car, and approached the pedestrian. Several bystanders also approached to assist.
  

• Emergency services were called at [Time] and arrived at the scene approximately [Number] minutes later.
  

Statement of Truth

I certify that the facts stated herein are true and correct to the best of my knowledge and belief. I understand that providing a false statement under oath could result in penalties under the law.

Further Affiant Sayeth Not

I have provided all known information regarding the incident as witnessed and have no further details to add at this time.

Subscribed and sworn to before me this         day of                               ,               .

Notarized by:

[Name of Notary Public]

[Notary Public, State of [State]]

[My commission expires: [Date]]

Seal:

[Notary Seal]

Law Firm Templates @ Template.net