108 Annex III: Model communication/complaint under UN human rights treaties Name of treaty: ........................................................................................................ 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