Fillable Va Form 21-1775 - Statement Of Disappearance (Page 6 of 6) in pdf

Va Form 21-1775 - Statement Of Disappearance Page 6

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65. DID THE MISSING PERSON OWN A

66. DID HE/SHE TAKE THE VEHICLE ALONG?

MOTOR VEHICLE?

YES

(If "YES", complete Item 66)

YES

(If "YES", give make, model, etc. and complete Item 67)

(Explain fully)

67. INDICATE WHETHER THE VEHICLE WAS RECOVERED AFTER THE DISAPPEARANCE OF THE MISSING PERSON

68. IF ANY EFFORTS WERE MADE TO LOCATE THE MISSING PERSON, FILL IN COLUMNS (A), (B) AND (C) BELOW

(A)

(B)

(C)

NAMES AND ADDRESSES OF AGENCIES AIDING

DATE

DESCRIPTION OF EFFORTS

(Including Police)

NOTIFIED

IN SEARCH

69. IF POLICE WERE NOT NOTIFIED, EXPLAIN THE REASON

70. HAVE YOU HEARD FROM MISSING PERSON, IN ANY WAY SINCE DISAPPEARANCE?

71. NAME AND ADDRESS OF THE PERSON RECEIVING

COMMUNICATION

72. POSTMARK DATE

73. ADDRESS SHOWN ON POSTMARK

74. DO YOU KNOW ANY REASON WHY THE MISSING PERSON SHOULD NOT REVEAL HIS/HER WHEREABOUTS?

75. WHAT IN YOUR OPINION, IS THE REASON FOR HIS/HER SILENCE?

76. HAS ANY COURT EVER BEEN ASKED TO DECLARE THE MISSING PERSON DEAD?

77. NAME OF COURT

(If "YES", complete Items 77, 78 and 79)

YES

78. DATE

79. RESULT OF COURT'S DECISION

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false.

CERTIFICATION - I certify that the foregoing statements made by me on this form are true and correct to the best of my knowledge and belief, and are made with full

knowledge of the fact that severe penalties involving fines and imprisonment are prescribed by various statutes of the United States for making a false statement.

DATE

SIGNATURE

(Number and Street or P.O. Box or Rural Route Number, City, State and ZIP Code)

ADDRESS

WITNESSES TO SIGNATURE IF MADE BY (X) MARK

NOTE: Signatures made by mark must be witnessed by two persons to whom the person signing this form is personally known, and the signatures

and addresses of such witnesses must be shown below.

SIGNATURE OF WITNESS

ADDRESS OF WITNESS

SIGNATURE OF WITNESS

ADDRESS OF WITNESS

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