CAT/OP/POL/CNPMRO/1 Annex II Reprisals notification to the National Mechanism for the Prevention of Torture Notification date: …………………. Notifying person’s name and surname: ………………….. Notifying person’s correspondence address …………………………………... Description of the circumstances which the applicant considers to be a manifestation of reprisals (indicating persons who may be the reprisals’ perpetrators and victims): ……………………….……………………………………………………………………… ……….………………………………………..............................…………………………… ……………………………………………………………………...………………………… …………………...……………………………………………………………………….. Names and surnames of persons who have or may have witnessed the circumstances described above: ………………………….….……….………………………………………………………… ……….……………………………….………………………………………………….…… ………………………………………….. I hereby declare that I provide this information to the best of my knowledge and that it does not constitute slander . I agree to disclose my personal data in order to investigate the matter notified. …………………………………………. (signature) 20