LIFE reference no:
Date form completed:
Against which State(s):
Who is completing this questionnaire on behalf of the victim:
Ⅰ. Identity:
Family name: Latin:
First name: Latin:
Sex: Male Female
Birth date or year at least:
Nationality / Nationalities:
Indigenous: Yes No
Pregnant Yes No  
Identity document(if any):
Issued by:
On date:
No. :
Profession and/or activity:
Family status: Married   Single
Has Children: Yes No
Nationality of spouse:
Nationality of children:
Address of usual residence:
Family address:
Contact details of:
• Family:
• Lawyer/Advocate:
Place of violation:
Ⅱ. Arrest:
Date of arrest:
Place of arrest:(as detailed as possible)
Identity of force(s) who carried out the arrest or are believed to have carried it out:
Were they in uniform or civilian clothes?
Did they show a warrant or other decision by a public authority? Yes No
Authority who issued the warrant or decision
Relevant legislation applied(if known)
Ⅲ. Charge:
Has there been a charge(s)? If yes ,how many? Yes No
Date of charge(s):
Nature of charge(s)/Accusations(or any available details you may have):
Who has brought the charge?
Ⅳ. Detention:
Date of detention:
Duration of detention:
Forces holding the detainee under custody:
All places of detention(indicate any transfer and present place of detention):
Dates from:
Any incommunicado detention (if so ,dates and places): Yes No

Authorities that ordered the detention:
Reasons for the detention imputed by the authorities:
Relevant legislation applied (if known):
Describe the circumstances of the detention and indicate precise reasons why you consider the arrest or detention to be arbitrary:
Indicate internal steps, including domestic remedies, taken especially with the legal and administrative authorities, particularly for the purpose of establishing the legal basis of the detention and, as appropriate, their results or the reasons why such steps or remedies were ineffective or why they were not taken?
Has there been any mistreatment or torture?(please provide details or fill in separate section concerning this): Yes No

Are there any relevant medical issues relating to the detention? (eg poor health, lack of access to medical treatment,specific health problems, hunger strikes, conditions of detention)? (please provide details) Yes No

Ⅴ. Contact with family:
When did the family last have contact with the detainee?
How frequently/many times have family had contact with detainee? Please provide details:
Situation of family members - eg women and children(problems they are facing, eg harassment,health):
Any other information:
Ⅵ. Extrajudicial, summary or arbitary executions:
Information regarding the incident:
The nature of the incident: Please describe the circumstances of the incident, including the following categories:
(a) death penalty, or fair trial guarantees, please detail (unfair laws or proceedings, charges, eventual appeals, execution is imminent, etc.)
(b) imminent violation of the right to life is feared (death threats, imminent expulsion or refoulement leading to a life-threatening situation, etc.), please detail.
(c) others (death in custody, death during an armed conflict, death due to excessive use of force by law enforcement officials, death due to attacks by security forces of State, paramilitary or private forces, breach of obligation to investigate, etc.):
Forces (State or State-supported) believed to be responsible for the extra-judicial execution
Identity of forces(s) responsible for the execution (for example, military, police, persons in uniform or civilian clothes, agents of security services, unity to which they belong, rank and functions etc) and why you believe they are responsible - be as precise as possible.
If identification as State agents is not possible, why do you believe that Government authorities, or persons linked to them, are responsible for the incident?
If there are witnesses to the incident, give their names.
If they wish to remain anonymous, indicate if they are relatives, by-passers, etc
Action taken by the relatives or others to locate the person (inquiries with police, jail, human rights commission, habeas corpus petition etc)
Have complaints been filed? Yes No
By whom?
Before which organ?
Have any other steps been taken? Yes No
If action was not possible, please explain why:
Steps taken by the authorities:
Indicate whether or not there have been investigations by the State authorities; if so, what kind of investigations? Progress and status of these investigations; which other measures have been taken (e.g. autopsy)? Yes No

In case of complaints by the victim or its family, how have the organs dealt with them? What is the outcome of those proceedings?
Identity of the person submitting the report:
Who is submitting the report? (if other than LIFE)
Does their identity need to be kept confidential? Yes No
Any other details?
Who is completing this questionnaire on behalf of the victim ?
What is their relation to the victim?
Contact details of the person completing the questionnaire:
Would you like LIFE to submit the information about the victim to the United Nations? Yes No
Would you like LIFE to speak about the case in public (for example: press release)? Yes No