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Witness Statement Template – New York
Use this template to document what was observed while keeping contacts, exhibits, and impact details in a structured format.
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Witness Statement Template
This Witness Statement is made on [Date] by:
Full Name of Witness: [First Name Last Name]
Address: [Full Address]
Phone/Email: [Contact Information]
Occupation: [Job Title or N/A]
Relationship to Case/Parties: [Relationship or N/A]
1. Event Overview
Date of Incident: [MM/DD/YYYY]
Time: [Time or Approximate Time]
Location: [Address or description of location]
Type of Matter: [Accident/workplace incident/civil dispute/other]
Immediate Outcome Observed: [Injury/property damage/argument/other/unknown]
2. Witness Identification
Witness Name: [Witness Name]
Best Contact Method: [Phone/Email]
Address at Time of Statement: [Full Address]
3. Statement Purpose and Reference
Case/Incident Reference: [Case name/claim #/internal file #/other]
Parties Mentioned: [Names or N/A]
How I Know the Parties (if applicable): [Relationship or N/A]
4. Statement of Facts (Who/What/Where/When/Why/How)
Who: [People involved and my relationship to them, if any]
What: [What I observed happen]
Where: [Where I was and where the events occurred]
When: [Timing and sequence as I recall it]
Why: [Reason/motive if directly observed; otherwise Unknown]
How: [How the events unfolded, including actions and movements]
5. Supporting Evidence
Exhibit A: [Photographs/Video files and identifiers]
Exhibit B: [Report/record/other]
Exhibit C: [Additional document/other]
Additional Exhibits: [List or N/A]
6. Declaration of Truth and Signatures
I, [Witness Name], declare that the facts stated in this witness statement are true to the best of my knowledge and belief.
I understand that making a false statement may result in penalties under applicable perjury laws.
Witness Signature: _______________________ Date: ___________
Printed Name: ___________________________
Interpreter Certification (optional): ________________________
Interpreter Name: ________________________ Language: __________
Signature: ______________________________ Date: ___________
7. Witness Matrix (Module)
Complete the witness matrix:
Name | Role | Contact | What They Observed | Media/Notes |
[Name] | [Witness/Party/Responder] | [Phone/Email] | [Summary] | [Photo/Video/None] |
[Name] | [Witness/Party/Responder] | [Phone/Email] | [Summary] | [Photo/Video/None] |
[Name] | [Witness/Party/Responder] | [Phone/Email] | [Summary] | [Photo/Video/None] |
8. Claim/Insurance Intake (Module)
Insurer/Carrier: [Name or N/A]
TPA/Administrator: [Name or N/A]
Policy/Account Number: [Number or N/A]
Claim Number: [Number or N/A]
Adjuster/Contact: [Name/Phone/Email or N/A]
Reported Date: [MM/DD/YYYY or N/A]
9. Impact Summary (Module)
Impact Type Observed: [Physical injury/property damage/emotional distress/other/unknown]
Functional Limitation Observed: [None/mild/moderate/severe/unknown]
Severity Scale (1–5): [1/2/3/4/5/Unknown]
Notes: [Observed effects and duration, if known]
10. Evidence Preservation (Module)
Photos/Video Captured By: [Name/Device]
File Names/IDs: [File names/IDs]
CCTV/Camera Identifiers (if any): [Camera ID/location/other]
Preservation Request Sent (if any): [Date/method/recipient]
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Easy-to-understand jargon
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Learn more about
Witness Statement Template – New York
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
New York Witness Statement Template FAQ
What is the advantage of using the Who/What/Where/When/Why/How structure?
This structure reduces ambiguity by forcing the statement to answer the same core questions reviewers ask during evaluation. It also helps separate facts you directly observed from background context or speculation. “Where” and “When” often clarify distance, sightlines, and sequencing, while “How” captures movement and mechanics. “Why” is included so you can record motive only when you actually observed it; otherwise, you can state “Unknown.” The end result is a statement that is easier to compare against other accounts and evidence.
How should a witness describe conversations or quotes?
If you remember exact words, record them as precisely as you can and note who said them and when. If you only remember the gist, describe the substance without inventing quotations. It can also help to note whether the conversation was overheard directly, heard through a phone speaker, or relayed by another person. If multiple statements were made, distinguish them in sequence. Clear labeling of what you heard versus what you inferred helps preserve credibility and reduces disputes about what was actually said.
What is the purpose of the witness matrix module?
The witness matrix is designed to capture key witness identities and what each person can confirm, all in one place. It can be used by investigators to coordinate follow-up interviews and avoid duplicative contact. Including “Media/Notes” helps track who may have photos, recordings, or additional documentation. Even if you only know partial information for a person, capturing what you do know can be valuable later. The matrix is especially helpful in crowded scenes where several people saw different parts of the event.
Should you include information you learned from other people?
You can include secondhand information if it is relevant, but you should clearly label it as something you were told rather than something you personally observed. Mixing hearsay into the same narrative as direct observation can create confusion and can make reviewers question what was firsthand. A good approach is to keep your main narrative focused on what you directly perceived and then add a separate sentence indicating who told you what, if needed. That separation makes the statement more reliable and easier to evaluate.
How do claims and insurance fields help even in non-insurance matters?
Claim-style fields provide a standardized way to track references, contacts, and reporting dates when multiple organizations are involved. Even in internal investigations, having an “adjuster/contact” style line can function as a designated case handler. This improves routing, reduces lost communications, and helps keep documents associated with the correct file. If a matter becomes formal later, these references can also help you retrieve the right records. The module is meant to improve organization, not to change the nature of the statement.
What should you do if you remember additional details after signing?
If you remember additional details later, avoid altering the signed statement in a way that obscures what was originally recorded. A common approach is to prepare a supplemental statement dated the day it is created, clearly explaining what you are adding or correcting. If the new detail is based on an objective source, such as a photo timestamp, note that source. Keeping the record transparent reduces the risk that the change looks like an attempt to reshape the account. Supplemental statements are often easier to review than rewritten originals.
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