Affidavit of Injury — Justice Cartel Investigative Vault

Affidavit of Injury Form

Full Name

Mailing Address (City, State)

Phone Number

Email Address

Preferred Contact Method

Date of Incident / Injury

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SECTION II – Statement of Injury

Describe the harm or injury you have suffered. You may include physical, emotional, financial, or constitutional impacts (e.g., denial of due process, discrimination, property seizure, unlawful arrest, retaliation, etc.).

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SECTION III – Responsible Party / Agency / Court

Identify the individuals, agencies, or courts responsible for or involved in the incident.

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SECTION IV – Evidence / Supporting Records

List any supporting documentation, records, or files (court documents, letters, emails, audio, photos, etc.).

Attach files using the secure upload feature below.

Upload file

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SECTION V – Remedy or Relief Sought

Explain what result or action you are requesting — investigation, accountability, restitution, public exposure, or policy reform.

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SECTION VI – Affirmation / Oath

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I affirm that the information provided is true and accurate to the best of my knowledge and belief.

I understand this submission is for educational and investigative purposes through the Justice Cartel and does not establish an

attorney-client relationship.

Notary / Witness Name

Date Field

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SECTION VII – Submission Notice

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Justice Cartel is an investigative and educational organization, not a law firm.

Nothing in this form constitutes legal advice. Submissions are encrypted and stored for record-keeping and pattern analysis as

part of the Justice Cartel Vault.