II. Information concerning the alleged victim(s) • Family name: ............................................................................. • First name: ................................................................................ • Date and place of birth:............................................................... • Nationality/citizenship: ............................................................... • Sex: ......................................................................................... • If you consider it appropriate, please indicate whether the alleged victim(s) has a disability and, if so, the nature of their disability: ........... ............................................................................................... • Other relevant personal identification data (if any of the above details are not available) ............................................................................. ............................................................................................... • Present address: ......................................................................... ............................................................................................... ............................................................................................... • Postal address for confidential correspondence (if other than present address): ...................................................................................... ............................................................................................... • Telephone or mobile number (if any): .............................................. • E-mail address (if any):................................................................. • Fax number (if any): .................................................................... • If the communication concerns a group of individuals claiming to be victims, please provide basic information about each individual, in line with the above list. III. Information on the State party concerned Name of the State party (country): ...................................................... IV. Subject matter of the communication .................................................................................................... 33