ANNEX IV

Model communication Date: ..............................
Communication to:
The Human Rights Committee c/o OHCHR
United Nations Office 8-14 avenue de la Paix
1211 Geneva 10, Switzerland

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 or violations set forth below 0
(b) Appointed representative/legal counsel of  the alleged victim(s) 0
8   Other 0
If  box 8 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