• Family name: ............................................................................. • First name: ................................................................................ • Sex: ......................................................................................... • Date of birth: ............................................................................. • Place and country of birth: ........................................................... • Address of usual residence ........................................................... .............................................................................................. • Do you wish the victim’s identity to be disclosed in the Committee’s final decision concerning your communication? Yes F No F If your communication refers to the enforced disappearance of a person(s), also provide the following information about the victim(s), if available (optional): • Other names by which he or she may be known .............................. • Profession/ Occupation/ Other relevant activity .............................. • Father’s name ............................................................................ • Mother’s name ........................................................................... • If relevant, ethnic background, belonging to an indigenous people or a minority, religious affiliation, membership in political or social group .... .............................................................................................. • Identity document (passport, national identity card, voter’s card or any other relevant national identity card): ............................................. • Was the person below 18 years of age at the moment of the disappearance? Yes F No F • Marital Status / Children .......................... / ............................... • Pregnant: Yes F No F If so, please specify if possible the number of months at the time of disappearance ................................................................................................ IV. Facts of the communication and articles allegedly violated • Please 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. • If possible, identify the articles of the Convention alleged to have been violated. • Explain how you consider that the facts and circumstances described violated rights of the Convention. If the communication refers to more than one provision, describe each issue separately. 38