• Date(s): .................................................................................... • Place(s): ................................................................................... • Results (if any): ........................................................................... Please note: Enclose copies of all relevant documentation. VII. Disclosure of your name(s) Do you consent to the disclosure of your name(s) to the State party should your communication be registered by the Committee in accordance with article 6, paragraph 1, of the Optional Protocol and rule 69, paragraph 1, of the Committee’s rules of procedure? Yes F No F VIII. Date and signature Date/place: ................................................................................... Signature of author(s) and/or victim(s): ................................................ IX. List of documents attached (do not send originals, only copies) .................................................................................................... .................................................................................................... .................................................................................................... 31