(e) Identity document:.............................................. Nr: .......................... Date of issue: .................................... Place of issue: ………………… (f) Address of usual residence:.................................................................. ............................................................................................................... ............................................................................................................... (g) Pregnant: yes __ / no __. 2. Date on which the disappearance occurred (*): Day: ............... Month(*): .............................. Year(*): of disappearance 3. ................. Place of arrest or abduction, or where the disappeared person was last seen (*): Location (if possible, street, city, province or other relevant indications): .............................................................................................................. .............................................................................................................. .............................................................................................................. 4. Forces (State or State-supported) believed to be responsible for the disappearance (*): (a) If the perpetrators are believed to be State agents, please specify (military, police, persons in uniform or civilian clothes, agents of security services, unit to which they belong, rank and functions, etc.) and indicate why they are believed to be responsible. Be as precise as possible: ............................................................................................................... ............................................................................................................... ............................................................................................................... 24