II. Information concerning the alleged victim(s) (if other than the author) • Family name: ............................................................................. • First name: ................................................................................ • Date and place of birth:............................................................... • Nationality/citizenship: ............................................................... • Passport/identity card number (if available): .................................... • Sex: ......................................................................................... • Marital status/children:................................................................ • Profession:................................................................................. • If relevant, ethnic background, religious affiliation, social group:................. • Present address: ......................................................................... ............................................................................................... • Postal address for confidential correspondence (if other than present address): ...................................................................................... ............................................................................................... ............................................................................................... • Telephone number/e-mail address: ................................................ III. Information on the State party concerned • Name of the State party (country): ................................................. IV. Facts of the complaint and nature of the alleged violation(s) Please detail, in chronological order, the facts and circumstances of the alleged violations, including: • Description of the alleged violation(s) and the alleged perpetrator(s): ........ ............................................................................................... ............................................................................................... ............................................................................................... • Date(s): ......................................................................................... 29