Certification of Peace Officers PA-1

for Police State Aid Payable in 2024

To avoid penalty, electronically submit this form by March 15, 2024

Instructions

County

Peace Officer Department

Minnesota Tax ID

Officers

Last Name

First Name

P.O.S.T. License

Original Hire

End Date

Months Employed

Hours per Week

Fund

Explain unpaid leave

Certification

I certify that I am authorized to submit this information and that it is true and correct to the best of my knowledge. I understand that anyone giving false information is subject to a fine of up to $3,000 and/or up to one year in prison. [Minnesota Statutes, section 609.43]

Certifier Name

Certifier Title

Certifier Phone Number

Certifier Email