Utah Missing Person Clearinghouse Report Form/waiver Page 2
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3UTAH MISSING PERSON CLEARINGHOUSE REPORT FORM/WAIVER
Be very specific, the more accurate and complete the information, the better the chances of identification.
MISSING PERSON
NAME: (LAST, First, Middle)
ALIAS/NICKNAMES:
SEX:
RACE:
PLACE OF BIRTH: (City, State, County)
DATE OF BIRTH:
AGE:
HEIGHT:
WEIGHT:
HAIR COLOR:
EYE COLOR:
BUILD:
DRIVERS LICENSE NUMBER:
SOCIAL SECURITY NUMBER:
HAIR LENGTH:
HAIR STYLE:
COMPLEXION:
UNIQUE CHARACTERISTICS (Scars, Limp, Tattoos, Jewelry, Glasses, Etc.)
DENTAL RECORDS AVAILABLE?
MEDICAL RECORDS AVAILABLE?
FINGERPRINTS AVAILABLE?
BLOOD TYPE:
9
9
9
9
9
9
YES
NO
YES
NO
YES
NO
9
9
MEDICAL PROBLEMS?
YES
NO
TYPE OF PROBLEM:
PRESCRIPTIONS:
MENTAL STATE (Depressed, Suicidal, etc.)
LOCATION LAST SEEN (Include City, State):
DATE/TIME OF LAST CONTACT:
POSSIBLE DESTINATION (City, State)
LAST SEEN WEARING:
HOBBIES AND INTERESTS(Dancing, Swimming, Surfing,
ASSOCIATIONS & HANGOUTS (Country Bars, Video Arcades, Bowling Alleys, Skating
Fishing, etc.)
Rinks, etc.):
INCIDENT TYPE:
9
9
9
9
9
9
9
RUNAWAY
PARENTAL ABDUCTION
ENDANGERED
INVOLUNTARY
DISABLED
DISASTER VICTIM
UNKNOWN
SUSPECT INFORMATION
IN COMPANY OF:
NAME: (LAST, First, Middle)
9 NON CUSTODIAL PARENT
9 ABDUCTOR
9 FRIEND
ALIAS/MAIDEN NAME:
SEX:
RACE:
PLACE OF BIRTH:
DATE OF BIRTH:
LAST KNOWN ADDRESS (Street, City, State, Zip)
PHONE:
AGE:
HEIGHT:
WEIGHT:
HAIR COLOR:
EYE COLOR:
SOCIAL SECURITY NUMBER:
DRIVERS LICENSE NUMBER (Include state):
OCCUPATION:
UNIQUE CHARACTERISTICS (Scars, Limp, Tattoos, Jewelry, Glasses, Etc.)
VEHICLE
MAKE:
MODEL:
VEHICLE YEAR:
TYPE/STYLE:
COLOR:
LICENSE
LICENSE YEAR
NUMBER:
OF EXPIRATION:
LICENSE STATE:
DESCRIPTION (Other identifying characteristics, noticeable damage, accessories, VIN):
PARENT / GUARDIAN / SPOUSE
PARENT/GUARDIAN/SPOUSE NAME; (LAST, First, Middle)
RELATIONSHIP:
STREET ADDRESS:
PHONE (Home & Work):
NOTE TO PARENT/GUARDIAN/SPOUSE CAREFULLY READ AND SIGN STATEMENT ON THIS FORM!
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