Annex IV MODEL FORM FOR THE SUBMISSION OF COMMUNICATIONS UNDER THE INTERNATIONAL CONVENTION FOR THE PROTECTION OF ALL PERSONS FROM ENFORCED DISAPPEARANCE Please provide relevant information in response to the items listed below. Your communication should not exceed 50 pages (without annexes). I. Information on the State party concerned • Name of the State party (country) alleged to have committed the violation – that is a party to the International Convention for the Protection of All Persons from Enforced Disappearance and – has made the declaration in accordance with article 31 of the Convention ............................................................................................... II. Information concerning the author(s) of the communication • Family name: ............................................................................. • First name: ................................................................................ • Address of usual residence: .......................................................... ............................................................................................... • Postal address for confidential correspondence (if other than present address): ...................................................................................... ............................................................................................... • Telephone number/e-mail address (if available): ............................... ............................................................................................... • If you are acting with the knowledge and consent of the victim, please provide that person’s authorization for you to bring this complaint; or • If you are not so authorized, please explain the nature of your relationship with that person: ......................................................................... and detail why you consider it appropriate to bring this complaint on his or her behalf: ............................................................................. • Do you wish your identity to be disclosed in the Committee’s final decision concerning your communication? Yes F No F III. Information concerning the alleged victim(s) If there is a group of individuals alleged to be victims, provide basic information about each individual. 37