Model communication to the Committee Against Torture Date: ................................... Communication to: The Committee Against Torture c/o Communications Branch, Centre for Human Rights, United Nations Office 8-14 Avenue de la Paix CH-1211 Geneva 10, Switzerland Submitted for consideration under the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. I. Information concerning the author of the communication Name: ............................... First name(s): ............................ Nationality: ........................ Profession: ............................... Date and place of birth: .................................................................. Present address: .......................................................................... Address for exchange of confidential correspondence (if other than present address): ........................................................................................... Submitting the communication as: (a) Victim of the violation or violations set forth below ............................... 0 (b) Appointed representative / legal counsel of the alleged victim(s) ................... 0 (c) Other ............................................................................... 0 If box (c) is marked, the author should explain: (i) In what capacity he is acting on behalf of the victim(s) (e.g. family relationship or other personal links with the alleged victim(s)): ........................................................................................... (ii) Why the victim(s) is (are) unable to submit the communication himself (themselves): ........................................................................................... An unrelated third party having no link to the victim(s) cannot submit a communication on his (their) behalf. II. Information concerning the alleged victim(s) (if other than author) Name: ............................... First name(s): ............................ Nationality: ........................ Profession: ............................... Date and place of birth: .................................................................. Present address or whereabouts: ........................................................... III. State concerned / articles violated / domestic remedies Name of the State party (country) to the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment against which the communication is directed: ........................................................................................... Articles of the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment allegedly violated: ........................................................................................... Steps taken by or on behalf of the alleged victim(s) to exhaust domestic remedies, recourse to the courts or other public authorities, when and with what results (if possible, enclose copies of all relevant judicial or administrative decisions): ........................................................................................... If domestic remedies have not been exhausted, explain why: ........................................................................................... IV. Other international procedures Has the same matter been submitted for examination under another procedure of international investigation or settlement (e.g. the Inter-American Commission on Human Rights, the European Commission on Human Rights)? If so, when and with what results? ........................................................................................... V. Facts of the claim Detailed description of the facts of the alleged violation or violations (including relevant dates)* ........................................................................................... Author's signature: ........................................................ * Add as many pages as needed for this description.