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Station/Post: Vila Date:
Place/Lieu: Vila Police Station Time/Heure: hrs
Name/Nom: Surname/Prenom:
Situation familiale: Celibataire Marie (e)/Concubinage Separe(e)/Divorce(e) Veuf/Veuve
Marital Status Single /Defacto Separated/Divorced Widow
Nationality/Nationalite: Ni-Vanuatu Ethnic Origin/origine ethnique:
Residential Status Ni Vanuatu Expartriate Tourist Visitor on Business
Status Residentiel Expartrie(e) Touriste Visiteur d’Affairs
Age: Sex (e) M F Religion:
Occupation/Profession:
Home Island/Village:
Business Address:
Residential Address:
Inteerpreter/interprete:
I hereby declare that my statement is the expression of the truth to the best of my knowledge and belief and is made by me knowing that I am liable to be prosecuted criminally if I willfully give information which I know to be false or do not believe to be the truth.
Je declare que ma deposition a la verite au mieux de ma connaisseance et de ma conviction. Je la fais en sachant que je m’impose a de poursuites judiciaries au cas ou je donnerais internationellement de informations fausses ou que je ne crois pas etre vraies.
Mi tallemaut se toktok blong mi ia I tru. Mi save se bambae mi go long kot sapos toktok blong mi hemi no tru or sapos mi ting se toktok we mi givim oli no tru.
Signature :
Signature :
Statement recieved by: _ _________Police Officer/Officier de Police
Station/Poste: _Vila_ ____on/Le: _ _ At/A ___ ___ Time/Heure: hrs__
The witness not knowing how to sign his/her statement was read to him/her in the presence of
Le temoin ne sachant pas signer, lecture de sa declaration a ete faite en presence de:
____________________now has signed his statement with us/ a signe le present process verbal avec nous.
_______________________________Davis SARAVANU ______________________
The witness The Police Officer The interpreter
Le temoin L’Officier de Police L’Interprete
