ANNEXES Annex III: Model Complaint Form for an Individual Communications under ICERD (Ref. Model questionnaires for communications or complaints at: http://www2.ohchr.org/english/bodies/docs/annex1.pdf) Contact Information: Mail: Petitions Team Office of the High Commissioner for Human Rights United Nations Office at Geneva 1211 Geneva 10, Switzerland Fax: +41 22 917 9022 (particularly for urgent matters) Email: tb-petitions@ohchr.org 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 Invoking individual complaint procedure under International Convention on the Elimination of Racial Discrimination (ICERD), Communication to: Committee on the Elimination of Racial Discrimination (CERD) 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 has made the relevant declaration: ………… Articles of the Covenant or Convention alleged to have been violated: ………… 42 ICERD & CERD: A GUIDE FOR CIVIL SOCIETY ACTORS