COMPLAINTS TO THE WORKING GROUP ON ARBITRARY DETENTION
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:

Arabic:
First name: Latin:

Arabic:
Sex: Male Female
Birth date or year at least:
Year:
Place of violation:
Country:
City:
Place:
Nationality / Nationalities:
Other:
Identity document(if any):
Issued by:
On date:
No. :
Profession and/or activity:(if believed to be relevant to the arrest/detention)
Address of usual residence:
Family status: Married   Single
Has Children: Yes No
Nationality of spouse:
Nationality of children:
Family address:
Contact details of:
• Family:
Name:
Mobile:
Email:
• Lawyer/Advocate:
Name:
Mobile:
Email:
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?
Authority who issued the warrant or decision:
Relevant legislation applied (if known)
Ⅲ. Charge:
Date of the charge:
Nature of charges/ Accusations (or any available details you may have)
Ⅳ. Detention:
Forces holding the detainee under custody:
All places of detention(indicate any transfer and present place of detention):
Place:
Dates from:
To:
Any incommunicado detention (if so, dates and place) Yes
No
When did the family last have contact with the detainee?   
How frequently/many times have family had contact with detainee? Please provide details:
Authorities that ordered the detention:
Reasons for the detention imputed by the authorities
Relevant legislation applied (if known):
Describe the circumstances of the arrest and/or 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 form concerning this): Yes No

Are there any relevant medical issues relating to the detention? (eg poor health, access to medical treatment, specific health problems, hunger strikes, conditions of detention)?(please provide details) Yes
No
Situation of family members – eg women and children(problems they are facing, eg harassment, health):
Any other details?
Confidentiality:
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:
Mobile:
Email:
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