The United Nations Human Rights Treaties
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Complaint Form to the Human Rights CommitteeDate: ................................................. 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 ........................................................................................................................................................... Address for exchange of confidential correspondence (if other than present address) ........................................................................................................................................................... Submitting the communication as: (a) Victim of the violation(s) (set forth below) ..........................................................................., or (b) Appointed representative/legal counsel of the alleged victim(s) ............................................., or (c) Other ............................................................................................................................................ If box (c) is marked, the author should explain: (i) In what capacity she or he is acting on behalf of the victim(s) (e.g. family relationship or other personal links with the alleged victim): ........................................................................................ (ii) Why the victim(s) is (are) unable to submit the communication her or himself (themselves): ........................................................................................................................................................... Note: An unrelated third party having no link to the victim(s) cannot submit a communication on her or 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 ever 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). Add as many pages as needed for this description. ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... Author's signature: ........................................................... 
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