SECTION 1 – Evidence Information
Date:	Time:
Place:
I,	have received from
Name of Person Receiving Evidence	Name of Person Releasing Custody of Evidence
the following item(s) of evidence
The above item(s) are being kept and used for evidence in the below styled case:
who stands charged with
Name of Person Being Charged
which occurred on or about
Charges Against Person
.
Date and Time of Charged Activity
SECTION 2 – Signature
Person Receiving Evidence Name (Print)	Person Receiving Evidence Signature	Date
Person Releasing Custody of Evidence Name (Print)	Person Releasing Custody of Evidence Signature	Date
SECTION 3 – Witness
Witness Name (Print)	Witness Signature	Date