Registro de Manifiesto de Involucrado

Declare acerca de lo sucedido con los detalles que considere importante para realizar sus descargos
respectivos como fecha, hora, nombres, lugares, entre otros

Fecha del evento:______________Hora:_________Lugar:_________________________________

Yo,_______________________________________________ DNI:__________________, mediante la

presente declaro lo siguiente:

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Fecha y lugar de llenado de registro:

Teléfono y lugar de domicilio:

Firma: