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 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)* .........................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................