1503 Model Complaint
Form
For communications under:
• Optional Protocol
to the International Covenant on Civil and Political Rights
• Convention against
Torture, or
• International
Convention on the Elimination of Racial Discrimination
Please indicate which of
the above procedures you are invoking: ………
Date:
………….
I. Information on the
complainant:
Name: ………
First name(s): ………….
Nationality:
……… Date and place of birth: ………….
Address for correspondence
on this complaint: ………..
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: ……….
If you are acting with the
knowledge and consent of that person, please provide that person’s
authorization
for you to bring this
complaint …………
Or
If you are not so
authorized, please explain the nature of your relationship with that person:
………………
and detail why you consider
it appropriate to bring this complaint on his or her behalf:
…………..
II. State
concerned/Articles violated
Name of the State that is
either a party to the Optional Protocol (in the case of a complaint to the
Human
Rights Committee) or has
made the relevant declaration (in the case of complaints to the Committee
against Torture or the Committee on the Elimination of Racial Discrimination):
…………
Articles of the Covenant or
Convention alleged to have been violated:
…………
III. Exhaustion of
domestic remedies/Application to other international procedures
Steps taken by or on behalf
of the alleged victims 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:
…………………..
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:
…………………………
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)?
……………
If so, detail which
procedure(s) have been, or are being, pursued, which claims you have made, at
which times, and with which
outcomes:
…………………………
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.
………………………….
………………………….
………………………….
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
other corroborating evidence you possess that substantiates your
description in Part IV of
the facts of your claim and/or your argument that the facts described amount to
a
violation of your rights:
…..…
If you do not enclose 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.