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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:  



Home Island/Village:   

Business Address:   

Residential Address: 


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 :  


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