Date: ...........................................................
Communication to:
The Human Rights Committee
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 Optional Protocol to the International Covenant on Civil and Political Rights.
I. Information concerning the author of the communication
Name: ...........................................................
First name(s): ...........................................................
Nationality: ...........................................................
Profession: ...........................................................
Date and place of birth: ...........................................................
Present address or whereabouts: ...........................................................
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 International Covenant and the Optional Protocol against which the communication is directed: ...........................................................
Articles of the International Covenant on Civil and Political Rights 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.