Date: .................................................
Submitted for consideration under the Optional Protocol to the International Covenant on Civil and Political Rights
I. Information on the complainant
Name ..................................................................................
First name(s) .......................................................................
Nationality...........................................................................
.
Date and place of birth........................................................
Address for correspondence on this complaint:
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Submitting the communication:
on the author’s own behalf:.................................................
on behalf of another person:...............................................
[If the complaint is being submitted on behalf of another person:]
Please provide the following personal details of that other person:
Name ..................................................................................
First name(s) .......................................................................
Nationality...........................................................................
.
Date and place of birth........................................................
Address or current whereabouts:
..............................................................................................
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If you are acting with the knowledge and consent of that person, please provide that person’s authorization for you to bring this complaint.............................................................................
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OR
If you are not so authorized, please explain the nature of your relationship with that person.....
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and detail why you consider it appropriate to bring this complaint on his or her behalf............
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II. State concerned/Articles violated
Name of the State that is a party to the Optional Protocol of the International Covenant on Civil and Political Rights:............................................................................................................
Articles of the International Covenant on Civil and Political Rights alleged to have been violated:
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III. Exhaustion of domestic remedies/Application to other international procedures
Steps taken by or on behalf of the alleged victim(s) to obtain redress within the State concerned for the alleged violation - detail which procedures have been pursued, including recourse to the courts and other public authorities, which claims you have made, at which times, and with which outcomes: ........................................................................................................................................
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If you have not exhausted these remedies on the basis that their application would be unduly prolonged, that they would not be effective, that they are not available to you, or for any other reason, please explain your reasons in detail:..................................................................................
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Have you submitted the same matter for examination under another procedure of international investigation or settlement (e.g. the Inter-American Commission on Human Rights, the European Court of Human Rights, or the African Commission on Human and Peoples’ Rights)? ...............
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If so, detail which procedure(s)have been, or are being, pursued, which claims you have made, at which times, and with which outcomes: ..........................................................................................
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IV. Facts of the complaint
Detail, in chronological order, the facts and circumstances of the alleged violations. Include all matters which may be relevant to the assessment and consideration of your particular case. Please explain how you consider that the facts and circumstances described violate your rights.
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Author's signature: ...........................................................
[The blanks under the various sections of this model communication simply indicate where your responses are required. You should take as much space as you need to set out your responses]
V. Checklist of supporting documentation (copies, not originals, to be enclosed with your complaint):
• Written authorization to act (if you are bringing the complaint on behalf of another person and are not otherwise justifying the absence of specific authorization)
• Decisions of domestic courts and authorities on your claim (a copy of the relevant national legislation is also helpful)
• Complaints to and decisions by any other procedure of international investigation or settlement
• Any documentation or corroborating evidence you possess that substantiates your description in Part IV of the facts of your claim and/or argument that the facts described amount to a violation of your rights
If you do not submit this information and it needs to be sought specifically from you, or if accompanying documentation is not provided in the working languages of the Secretariat, the consideration of your complaint may be delayed.