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Acknowledgment of Theft Affidavit

Blue Bucket Group, LLC

Name of Agent

First NameLast Name

Date:

Time:

Location:

Offense/Activity

Total Amount of Merchandise Cost:

Report What Happened:

Where did this happen in the store?

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 NameLast 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 NameLast 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: