VA Form 21-1775 Statement of Disappearance

VA Form 21-1775 is a United States Department of Veterans Affairs form also known as the "Statement Of Disappearance".

The form was last revised on December 1, 2010 - download an up-to-date fillable PDF VA Form 21-1775 down below or find it on the Veterans Affairs Forms website.

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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:www.reginfo.gov/public/do/PRAMain . 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
NO
(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
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:www.reginfo.gov/public/do/PRAMain . 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
NO
(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
23. DID THE MISSING PERSON LIVE CONTINUOUSLY WITH SPOUSE FROM DATE OF MARRIAGE TO DATE OF DISAPPEARANCE?
NO
(If "NO", give dates of all separations and the reasons therefore)
YES
24. WAS THE MISSING PERSON OR HIS/HER SPOUSE ENAMORED WITH OR INTERESTED IN ANOTHER PERSON?
(If "YES", give details)
YES
NO
25. INFORMATION ABOUT FAMILY OF MISSING PERSON
(List all children, brothers, sisters, mother and father)
NAME
AGE
RELATIONSHIP
ADDRESS
DATE OF DEATH
26. RELATIVES AND FRIENDS WHOM THE MISSING PERSON VISITED FROM TIME TO TIME, OR WITH WHOM HE CORRESPONDED, ETC.
NAME
RELATIONSHIP
ADDRESS
27. WAS THE MISSING PERSON IN GOOD HEALTH AT THE TIME OF HIS/HER DISAPPEARANCE?
(If "NO", explain fully)
YES
NO
28. DID THE MISSING PERSON APPEAR NORMAL WHEN LAST SEEN BY YOU?
YES
NO
(If "NO", explain fully)
29. STATE NAMES AND ADDRESSES OF ANY DOCTORS WHO ATTENDED THE MISSING PERSON AND DATES OF TREATMENT
30. HAD THE MISSING PERSON EVER BEEN TREATED FOR MENTAL ILLNESS?
YES
NO
(If "YES", state where and by whom, or in what institution, and whether an inmate of the institution)
PAGE 2 OF 6 PAGES
VA FORM 21-1775, DEC 2010
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
46. DID THE MISSING PERSON BELONG TO ANY UNIONS, LODGES, OR SOCIETIES?
(If "YES", give the names and addresses of the organizations)
YES
NO
47. HAVE ANY BENEFITS BEEN PAID BY ANY UNIONS, LODGES, OR SOCIETIES OF WHICH THE MISSING PERSON WAS A MEMBER, BASED ON HIS
UNEXPLAINED ABSENCE?
(If "YES", explain the kind of benefits, amounts, and to whom paid)
YES
NO
48. HAS A CLAIM FOR BENEFITS BEEN FILED WITH THE SOCIAL SECURITY ADMINISTRATION BASED ON THE INDIVIDUAL'S UNEXPLAINED ABSENCE?
(If "YES", complete columns (A), (B), and (C) below)
YES
NO
(A)
(B)
(C)
NAME AND ADDRESS OF EACH PERSON CLAIMING BENEFITS
WHERE EACH CLAIM WAS FILED
ACTION TAKEN ON EACH CLAIM
(Other than the Department of Veterans Affairs)
49. HAS A CLAIM FOR BENEFITS BEEN FILED WITH ANY OTHER AGENCY OF THE U.S. GOVERNMENT
OR ANY
STATE OR POLITICAL SUBDIVISION THEREOF, BASED ON THE MISSING PERSON'S UNEXPLAINED ABSENCE?
(If "YES", explain fully and give name of agency, name and address of each person claiming benefits, and the action taken on each claim)
YES
NO
50. DID YOU KNOW WHETHER ANY OF THE FOLLOWING CONDITIONS EXISTED AT THE TIME THE MISSING PERSON WAS LAST SEEN?
(Answer Items 50A, 50B, 50C, 50D and 50E below)
(Civil or Criminal - such as divorce action, indictment, court order or decree requiring support of wife
50A. WERE ANY COURT PROCEEDINGS PENDING?
or children, etc.)
(If "YES", explain)
YES
NO
50B. HAD A WARRANT FOR ARREST BEEN ISSUED?
50C. WAS THE MISSING PERSON SERIOUSLY IN DEBT?
(If "YES", explain)
(If "YES", explain)
YES
NO
YES
NO
50D. WAS ANY DISSATISFACTION EXPRESSED BY THE MISSING PERSON WITH SURROUNDINGS, WORK, HOME CONDITIONS, ETC?
(If "YES", explain)
YES
NO
50E. HAD THE MISSING PERSON SUFFERED A SERIOUS DISAPPOINTMENT OR BEREAVEMENT?
(If "YES", explain)
YES
NO
51. WHAT KIND OF REPUTATION DID THE MISSING PERSON HAVE IN THE COMMUNITY FOR BEING STEADY, SOBER, AND HARDWORKING?
VA FORM 21-1775, DEC 2010
PAGE 4 OF 6 PAGES
52. WHAT WERE THE MISSING PERSON'S HOBBIES, HABITS, AND INTERESTS?
53. DID THE MISSING PERSON TAKE ANY LONG TRIPS OR VACATIONS?
YES
NO
(If "YES", with whom and where did the missing person usually travel?)
54. DID THE MISSING PERSON USUALLY KEEP SOMEONE INFORMED OF HIS/HER WHEREABOUTS?
(If "YES", who usually knew?)
YES
NO
(Explain fully)
55. INDICATE WHETHER THE MISSING PERSON TALKED ABOUT ANY PARTICULAR LOCATIONS, STATES OR COUNTRIES
56. DID THE MISSING PERSON EVER GO AWAY BEFORE FROM HIS HOME OR FAMILY WITHOUT EXPLANATION?
(If "YES", explain fully)
YES
NO
IV - INFORMATION REGARDING MISSING PERSON'S DISAPPEARANCE
INSTRUCTIONS: Give exact dates if possible. Attach copy of reports of police or other agencies, newspaper items, letters and notes or other evidence relating to the
disappearance. Also attach a copy of any court proceedings declaring the missing person to be dead. THIS EVIDENCE WILL BE RETURNED TO YOU.
57. DATE DISAPPEARED
58. DATE LAST REPORTED SEEN BY ANYONE
59. PLACE LAST SEEN BY ANYONE
60. STATE CIRCUMSTANCES OF THE OCCASION WHEN THE MISSING PERSON WAS LAST SEEN AND THE NAME AND ADDRESS OF THE PERSON WHO LAST
SAW HIM/HER
61. DID THE MISSING PERSON ADVISE ANYONE OF AN INTENTION TO TRAVEL?
(If "YES", what was the planned destination?)
YES
NO
62. GIVE NAMES AND ADDRESSES OF ANY PERSONS WHO WERE FAMILIAR WITH THE MISSING PERSON'S PLANS
63. WERE YOU TOLD THE REASON FOR LEAVING OR DO YOU HAVE ANY KNOWLEDGE OR OPINION AS TO THE MISSING PERSON'S REASON FOR
LEAVING?
(If "YES", explain)
YES
NO
(Include clothing, traveling bag, trunk, money, etc.)
64. WHAT PERSONAL BELONGINGS DID THE MISSING PERSON TAKE WITH HIM/HER?
VA FORM 21-1775, DEC 2010
PAGE 5 OF 6 PAGES

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