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Acknowledgment of Theft Affidavit

Blue Bucket Group, LLC

Name of Agent *

First Name Last Name

Date: *

Time: *

Location: *

Offense/Activity *

Conceal Item Remove Tag Switch Tag Arrest

Total Amount of Merchandise Cost: *

Report What Happened: *

Signature of AGENT observing perpetrator shoplifting under New Jersey Statues 2C:20-11 from the Blue Bucket location identified above with the intent to avoid payment. *

Name of Blue Bucket SUPERVISOR as a witness: *

First Name Last Name

Blue Bucket SUPERVISOR fills in how many months is the perpetrator banned from the store *

Signature of Blue Bucket SUPERVISOR: *

Name of PERPETRATOR: *

First Name Last Name

Signature of PERPETRATOR acknowledging and understanding that I have shoplifted under New Jersey Statutes 2C:20-11 merchandise from Blue Bucket Group, LLC with the intent to avoid payment. I further understand that I am prohibited from entering the premises of any Blue Bucket Group, LLC store and failure to comply will likely result in my arrest for criminal trespass. *

Photo of Perpetrator: *

Photo of Perpetrator ID:

Photo of Merchandise: *