Greensboro Truth and Reconciliation Commission

WRITTEN STATEMENT FORM

Please print or type

Statement Givers’ Biographical Information

Name__________________________________________________

Birth Date________________Birth Place______________________________

Current Address________________________________________________________

Mailing Address (if different from above)______________________________

Address in Nov 1979 (if applicable)__________________________________

What do you wish to tell the Commission? Your statement may relate to the events of November 3,1979, any events/trends you believe contributed to the violence, and/or the impacts the violence had on the community. (Attach extra sheets as necessary)

Please complete the consent form on the reverse of this page.
Public Hearings
The Commission will hold four public hearings in which some individuals will make their statements in public.  Due to time constraints, not every statement giver will have this opportunity. However, the Commission would like to inquire about your willingness to participate at a hearing. Staff would inform you at a later date if you are invited to speak.  Please check the appropriate statement below.

___ I am willing to give my statement in a public hearing.
___ I prefer not to give my statement in a public hearing

Internet Accessible Statements
In an effort to share as much information with the community as possible, if you wish, the Commission may make your statement available as a sound file on our website (www.greensborotrc.org). Please check the appropriate statement below.

___ I am willing for my statement to be posted on the website.
___ I prefer not to have my statement posted on the website.

Informed Consent 
The Commission would like to use your statement, including names and other identifying information, in its final written report and other publications, as well as the public archive of the statements and other information the Commission plans to make available after the end of its mandate.  Please check the appropriate statement below.

___I understand and accept these terms for the use of my statement 
___I understand and consent to these terms for the use of my statement with the  EXCEPTION that I do not consent to the Commission’s voluntary disclosure to the public of: (check one or both)  
	___ my identity   
	___ names mentioned by me  

Future Contact
From time to time, media people and academic researchers ask us for contact information of those who have submitted statements. Please check one:

___Yes, I agree to have my name & contact information released to media and academic researchers
___No, I do not wish to have my name & contact information released 

Certification of Accuracy 
I certify that the statement I have given is true to the best of my knowledge.

___________________________________		_______________
Statement Giver's Signature				Date