COMPLAINTS TO THE WORKING GROUP ON ENFORCED AND INVOLUNTARY DISAPPEARANCES
(EID)
Against which State(s):
Who is completing this questionnaire on behalf of the victim:
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:
Arrest:
Date of arrest:
Where arrested from (address,city, province etc)?
Identity of forces(s) carrying out the arrest (police, intelligence services, armed forces, paramilitary, prison officials, other):
Were they in uniform or civilian clothes?
Did they show a warrant or other decision by a public authority? Yes No
Circumstances of arrest (eg mistreatment, beaten)
Date of Disappearance:
Place of Disappearance:
Identity of forces(s) responsible for the disappearance (police, intelligence services, armed forces, paramilitary, prison officials, other):
Any places he was seen after arrest/disappearance:
Place:
Dates :
Action taken by relatives?
Were any domestic remedies pursued by the victim or his/her family or representatives (complaints with the forces responsible, the judiciary, political organs, etc.)? If so, what was the result? 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