Fillable Va Form 21-1775 - Statement Of Disappearance printable pdf download

OMB Approved No. 2900-0036

Respondent Burden: 2 hours 45 minutes

STATEMENT OF DISAPPEARANCE

INSTRUCTIONS -All questions should be answered in detail and as fully as possible. If you do not know the answer to any question, state "unknown".

If you need more space to answer any questions, attach a blank sheet of paper, numbering the answers to correspond with any questions appearing in the

statement. You can call VA for free information and help in completing this form toll-free at 1-800-827-1000, (TDD) 1-800-829-4833.

(Print or Type)

FILE NO.

FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

XC-

Print or Type)

(Spouse, Mother, Child, etc.)

FIRST NAME - MIDDLE NAME - LAST NAME OF CLAIMANT (

RELATIONSHIP TO MISSING PERSON

(REFERRED TO AS "MISSING PERSON") (Print or Type)

FIRST NAME - MIDDLE NAME - LAST NAME OF PERSON WHO DISAPPEARED

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or

Title 5, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies,

the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA

benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,

and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits.

Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive

VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans

Affairs.

RESPONDENT BURDEN: We need this information to determine presumption of death for a missing veteran (38 U.S.C. 108). Title 38, United States Code, allows us to

ask for this information. We estimate that you will need an average of 2 hours and 45 minutes to review the instructions, find the information and complete this form. VA

cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if

this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at http: . If desired, you can

call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

I - INFORMATION REGARDING PERSON COMPLETING FORM

(Print or Type)

2. LENGTH OF TIME MISSING PERSON KNOWN

1. FIRST NAME - MIDDLE NAME - LAST NAME

(Spouse, mother, close friend, casual friend, etc.)

(Mother, close friend, casual friend, etc.)

4. RELATIONSHIP TO MISSING PERSON

3. RELATIONSHIP TO CLAIMANT

II - INFORMATION REGARDING MISSING PERSON

5. DATE OF BIRTH

6. BIRTHPLACE

7. FATHER'S FULL NAME

8. MOTHER'S FULL MAIDEN NAME

9. NICKNAMES OR ASSUMED NAMES OF THE MISSING PERSON

10. HEIGHT

11. WEIGHT

12. COLOR AND LENGTH OF HAIR

13. COLOR OF EYES

(Check)

15. RACE

14. DID THE MISSING PERSON WEAR A BEARD OR MUSTACHE?

BEARD

MUSTACHE

CLEAN SHAVEN

16. DESCRIBE IN DETAIL ANY TATTOO MARKS, ANY PHYSICAL DEFECTS, OR ANY IDENTIFYING MARKS

17. AT WHAT ADDRESS DID THE MISSING PERSON LIVE AT TIME OF DISAPPEARANCE?

18. WITH WHOM DID HE/SHE LIVE AT TIME OF DISAPPEARANCE?

(Check one)

20. WAS THE MISSING PERSON ON GOOD TERMS WITH HIS OR HER FAMILY AND ACQUAINTANCES?

19. MARITAL STATUS

(If "NO", explain fully)

YES

SINGLE

MARRIED

WIDOWED

DIVORCED

21. IF THE MISSING PERSON WAS DIVORCED, INDICATE THE REASONS FOR DIVORCE AND THE DATE AND PLACE WHERE DIVORCE WAS GRANTED

22. IF THE MISSING PERSON WAS MARRIED, INDICATE THE NAME AND ADDRESS OF SPOUSE AND COMPLETE ITEMS 23 AND 24

21-1775

VA FORM

EXISTING STOCKS OF VA FORM 21-1775, AUG 2007,

PAGE 1 OF 6 PAGES

DEC 2010

WILL BE USED

Va Form 21-1775 - Statement Of Disappearance

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