Date: .................................................
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
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Address for exchange of confidential correspondence (if other than present address)
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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):
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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 ..........................................................................................................
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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:
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Articles of the International Covenant on Civil and Political Rights allegedly violated:
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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):
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If domestic remedies have not been exhausted, explain why:
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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?
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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.
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Author's signature: ...........................................................