Va Form 21-1775 - Statement Of Disappearance Page 3

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III - BUSINESS, LEGAL AND SOCIAL AFFAIRS
31. MISSING PERSON'S SOCIAL SECURITY NUMBER
32. IF SOCIAL SECURITY NUMBER IS NOT KNOWN, DID MISSING PERSON EVER HAVE A
SOCIAL SECURITY NUMBER?
YES
NO
33. TRADE OR OCCUPATION
34. EMPLOYMENT HISTORY OF MISSING PERSON FOR LAST TEN-YEAR PERIOD
VA FORM 21-1775, DEC 2010
EMPLOYMENT DATES
TYPE OF WORK
NAME AND ADDRESS OF EMPLOYER
PERFORMED
BEGINNING
ENDING
35. WAS THE MISSING PERSON BONDED?
36. NAME AND ADDRESS OF BONDING COMPANY
(If "YES", complete Items 36 and 37)
YES
NO
37. CONDITION OF ACCOUNTS AT TIME OF DISAPPEARANCE
38. DID THE MISSING PERSON HAVE ANY LIFE INSURANCE POLICIES?
(If "YES", state name and address of the life insurance company, type of insurance, and policy number)
YES
NO
39. WHAT SETTLEMENT HAS BEEN MADE OF THE INSURANCE?
40. DID THE MISSING PERSON HAVE A BANK ACCOUNT
41. NAME AND ADDRESS OF BANK
AT TIME OF DISAPPEARANCE?
YES
NO
(If "YES", complete Items 41, 42 and 43)
42. AMOUNT OF FUNDS ON DEPOSIT IN BANK
43. WHAT HAS BEEN DONE WITH FUNDS ON DEPOSIT IN BANK?
$
44. DID THE MISSING PERSON HAVE A SAFETY DEPOSIT BOX?
(If "YES", what has been done with the contents of the box?)
YES
NO
(Check where applicable and explain below what has been done with the item(s) checked)
45. DID THE MISSING PERSON HAVE ANY OF THE FOLLOWING?
BUILDING AND LOAN SHARES
REAL ESTATE
SECURITIES
OTHER PROPERTY
VA FORM 21-1775, DEC 2010
PAGE 3 OF 6 PAGES

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