How to complete the individual application form for ......INSTRUCTIONS - APPLICATION FOR INDIVIDUAL...

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How to complete theindividual application form

for participation and/orreparations in

ICC proceedings0

IN STRU CTION S - A PPL IC ATI ON FOR I N DIV ID U AL V ICT I MS’ PART IC IP ATIO N 2 / 12

How to complete the application form for participation and/or reparations

These guidelines pertain to the application form which is designed for individual victims. Itdoes not refer to the form for groups of victims or organizations. Please complete thisapplication form if you or someone you are acting on behalf of has suffered harm as a result of acrime under the jurisdiction of the International Criminal Court (ICC), and wish to part icipateand/or submit a claim for reparations in proceedings before the ICC. The form has beendesigned to obtain all the information needed for your application.

Before completing the form please read the following instructions carefully. They will help you fillout the form correctly. For a better understanding of the ICC and the victim participation process ingeneral, please refer to the ICC Victims Participation and Reparations Section (VPRS) informationbooklet on the ICC website.

Every victim applying to participate and/or claim reparations in ICC proceedings must completetheir own separate application form. When filling in the application form:

• Please answer all questions as completely as possible. If some questions are not answered, orare only partially answered, the form may be considered by the ICC as incomplete.

• Please note the space limitations of this form. If more space is needed to answer certainquestions, please continue on a separate sheet of paper and attach it to the application form.The victim’s name and signature should be indicated on each sheet of paper attached to theapplication.

• Please write clearly, preferably in black.

The ICC Judges will decide whether the applicant is a victim of a crime under the jurisdictionof the ICC, whether the applicant is entitled to participate in the proceedings and, in theevent of a conviction, whether the applicant is entitled to reparations. Applications which arenot transmitted to the judges remain in the custody of the Registry of the ICC.

The judges decide whether the information contained in the form, including the applicant’sidentity, will be forwarded to the Prosecutor and to the Defence. Please note that some ofthe information provided may be made available to the public in the course of judicialproceedings.

If the applicant has security concerns regarding their engagement with the ICC or relating toany information contained in the application form, these concerns should be written down inresponse to Question 6. Please be aware that, despite raising security concerns, informationrecorded in the application may still be shared with the judges and/or the parties duringthe course of proceedings.


Are you a victim, or a person acting on behalf of a victim?

Throughout the application form, the person that suffered the harm is referred to as the victim.Please note the difference between a victim and a person acting on behalf of a victim for thepurposes of the ICC:

Page 1

A person acting on behalf of a victim is:an individual who presents an applicationto the ICC on behalf of another person whois the victim. This is the case for:• victims who are unable to present their

application themselves (children,persons with disabilities affecting theirability to present an application)

• victims who prefer to ask someone elseto present an application on their behalfand have given their consent forsomeone else to do so.

A victim is:• a person who has suffered direct harm

as a result of a crime within thejurisdiction of the ICC (direct victim)

• a person who suffered harm as a resultof crime(s) targeting another personrelated to them (indirect victim).

(For example, if the person is a family member of avictim who died or suffered other types of harm asa result of a crime within the jurisdiction of the ICC,he/she must fill in a form on his or her own behalfdetailing the crimes and his/her personal harmresulting from the loss of his/her family member).

This section refers to the victim, not the person acting on behalf of the victim.

A copy of proof of identity of the victim should be submitted with the form (for example, national identity card, birthcertificate, voting card, passport, driver’s license, student or employment card, letter from a local authority, campregistration card, card from a humanitarian agency, tax document). When you submit your application form by mail:Only attach copies of documents, not originals.If any information in the form is different from the information on the identity document provided (for example, namespelling, date of birth), please explain the reason for the difference next to the answer, or on a separate sheet clearlyreferencing the error/discrepancy.

Please state the gender the victim identifies with.

If the victim’s date of birth or age is unknown, please give an approximate date or age; if not possible, provide anyinformation that could assist in determining/approximating age.

Enter the victim’s nationality(ies). If the victim is stateless, this should be mentioned here.

If applicable, enter the victim’s ethnic group or tribe.

C

A

B

D

DC

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EA B

C

D


Victims may choose to participate in proceedings and request reparations using this form. If the victim would like toapply for both participation and reparations, the victim should tick the box “PARTICIPATION AND REPARATIONS”.Please note however, that pages three to five may be submitted separately and at a later date should the victimneed additional time to complete. Please also note that additional supporting documents related specifically toverifying reparation claims (that are not readily available at the time the victim completes the form) need not beincluded at this time for the validity of the form.

Should the victim only wish to participate, meaning, providing their views and concerns about the courtproceedings through a lawyer who represents the victim in the courtroom, the victim should only tick the“Participation” box. If the victim only wishes to participate, the victim need only complete pages 1 and 2 of theapplication form. Please consult the VPRS information booklet for more information about participation in ICCproceedings.

Should the victim only wish to request reparations, the victim should only tick the “Reparations” box.Reparations can be anything which can help the victim to redress the harm suffered. This can includecompensation, various forms of assistance, restitution of property, and/or symbolic or moral measures such aspublic apologies. If the victim only wishes to claim reparations, the victim still needs to complete all five pagesof the application form. Please consult the VPRS information booklet for more information about reparations.

Page 1 (continued)

Please be specific. If possible, provide the exact date on which the incident(s) occurred (day/month/year). If thedate of the events is unknown, please give an approximate the date of events (for example, proximity to major,known events, like a religious holiday, elections, any public memorial, publicly reported armed attacks, as the casemay be). If possible, provide name of a town or city where or near to the place where the incidents occurred.

Please be as specific as possible about what happened to the victim. It is important to provide a clear descriptionof the facts and details of the victim’s personal impressions. It is in the interest of the victim to provide a clear andfactual account of the events that happened to the victim, precisely as he/she remembers them.If different events took place at different date(s) and/or place(s), please clearly explain each relevant event andrecord the date when it occurred.

Information should be provided about the exact nature of the injury, damage, or suffering that the victim haspersonally experienced as a result of the actions or events described in Question 2.The ICC recognises different types of harm that a victim suffers as a result of crimes that the ICC has jurisdictionover. These crimes can cause physical suffering to a person’s body, emotional or psychological suffering or mentalharm, by which a person’s mind is affected because of what he/she has experienced or witnessed.Material harm could also be recognised; for example loss of, or damage to property as the result of a crime in theICC’s jurisdiction. If the events resulted for example in impairment to work or loss of educational opportunities,please explain what the activity was and how the activity has been affected.


SIGNATURES: It is very important that one or both of the two signature boxes on the bottom of Page 1 is completed.The box above (the first signature box on the form) is when a victim applies on their own behalf. By signing the form, theapplicant is verifying the authenticity of the application. This serves to demonstrate that the victim is taking responsibility forthe content of the information given in the form and its accuracy, even if someone else has actually written it down. Bysigning, the victim also confirms their intention to submit an application.

If the person is not able to write, for example if they are illiterate, they may make a personal mark, or put their thumbprint.

If the victim is an adult who gives consent for someone to act on their behalf, both persons (the applicant and the personacting on their behalf) should sign, or the applicant should provide their written consent in a document appended.

If the applicant does not know who the person(s) allegedly responsible for these events are, it is sufficient to providesome information that would identify the group to which the individuals belong (for example, a description of theuniforms worn by alleged perpetrators or language spoken by alleged perpetrators, etc.).If the victim does not know who is responsible for the events, the victim can simply reply “not known” in the boxprovided.

AB-C-

Please clarify if the victim still suffers from the harm. If so, please indicate if the continued suffering affects othersthat are dependent on the victim for financial or other support.

If the victim has documents demonstrating the harm suffered, please attach copies to the form. This includes forexample medical records, proof of economic loss, proof of loss or damage to property or any other documentproving the harm caused as described.

If the victim suffered harm as a result of crime(s) targeting their family member(s), in addition to documentsestablishing the identity of both the victim and the family member, proof of kinship (or close relationship) betweenthe two should be submitted together with the form. Examples include: (i) a birth, marriage or death certificate; or(ii) a declaration from two witnesses, together with copies of the witnesses’ identity documents.

Finally, if possible, please attach copies of any documents substantiating the harm suffered (for example: deathcertificates, medical records, etc.).

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Before signing the form, the victim should either read the form in its entirety/ or have the person assistingthe victim read it back to him/her to ensure the accuracy of the information provided.

After the form is signed by the victim, the form should not be altered in any way (for example, by adding orremoving information). If the victim wishes to modify his/her declaration, he/she should contact the VPRSwhich will provide a specific form to that effect.

Page 2: Personal information

The victim can express their concerns, not only about physical security but also about harm to their psychologicalwell-being, reputation, privacy and/or dignity or those of their family as a result of their relation and interactionwith the ICC.

Please explain the reasons that motivate the victim to participate in the ICC proceedings. For example, “to helpestablish the truth”; “to obtain justice”; “to obtain reparations”, etc.

Victim is a child: According to the Convention on the Rights of the Child, every person below the age of 18 is achild; therefore an adult related to the child has to present the application acting on their behalf. A document(copy) providing proof of kinship has to be attached to the application form. Proof of kinship could be any relevantofficial documentation attesting to such kinship (names & relationship). It can also be a declaration from twowitnesses, submitted alongside copies of their identity documents.

Victim has a disability: If the victim has a disability that affects their ability to present an application, then aguardian can present the application acting on their behalf. A document (copy) providing proof of guardianship hasto be attached to the application form. Proof of guardianship could be any relevant official documentation attestingto such guardianship (names and legal relationship). It can also be a declaration from two witnesses, submittedalongside copies of their identity documents.

Victim is an adult: If the victim is an adult and prefers that someone related to them presents the application ontheir behalf. In this case, it is very important that the victim expresses consent by attaching a letter of consentsigned by the victim, or by signing the victim’s signature box of Page 1. In both cases, the person acting on behalfneeds to sign the ‘person acting on behalf signature’ field.

Proof of identity of the person acting on behalf of the victim must be attached to the form. Valid identitydocuments are: national identity card, birth certificate, voting card, passport, driver’s license, student or employeecard, letter from a local authority, camp registration card, card from a humanitarian agency, tax document or otherdocument identifying the person.

A

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I] In order to represent victims before the ICC, a lawyer must be on the ICC list of counsel. Lawyers who are notlisted but that meet the criteria established by the ICC may apply for inclusion on the list. Please consult the VPRSinformation booklet for more information about legal representation.

II] If the applicant can afford to pay for a lawyer who will represent them in the ICC proceedings, please confirmhere.

III] When there are many victims participating in the proceedings, the ICC may decide to group them and appointone lawyer, or a team of lawyers, to represent them. Please provide an explanation if the applicant believes thatall the victims or specific groups of victims cannot be represented by the same lawyer or team of lawyers.

IV] The victim may list here any particular characteristics and qualities they prefer in a lawyer, or a team oflawyers. These preferences will be considered by the ICC if it becomes necessary to organise the representation ofvictims participating in the proceedings. For example, victims may wish their lawyers to be from the same countryor speak the same language. The ICC also has an independent Office of Public Counsel for Victims which canrepresent victims in the proceedings free of charge.

Indicate the number of people such as children, spouse(s), orphans or other family members who are dependenton the victim for financial or other support.

Indicate any form of impairment, not necessarily resulting from the alleged crimes, that may impact on the victim’shealth, mobility, cognitive ability or decision-making capacity.

So that the ICC can communicate with the victim in a language the victim understands, it is important that we havean indication of the victim’s first and main language. Keep in mind that the ICC usually works in French and English,but may decide to also work in other languages.

Please be aware that concerns raised about security may not prevent information in the application from being givento the parties and may not result in the ICC offering protection. For more information about security in the applicationprocess please consult the VPRS information booklet.


This could be the victim’s own contact details, or those of a family member or other individual if the victimprefers to be contacted through someone else. Please indicate if the address given is not that of the victim.If the victim expects to relocate, please provide the name and address of a trusted person who would know howto contact the victim, and who is aware of the application being submitted.

This section does not request the details of a person acting on behalf of a victim. This box should be filled out ifthe victim or person acting on behalf of the victim was assisted in completing the form.

If the victim or the person acting on behalf of the victim completed the form unassisted, this section should beleft blank.

Please also provide the name of the person who provided interpretation, if there was one.

Victims are requested to provide photocopies of documents such as proof of identity or proof of kinship. Please donot send original documents. Photocopies of documents not specifically requested but that might be relevant to theapplication such as forensic, medical, police or court records, photographs, films, etc. should also be attached to theapplication if available. All documentation provided (including the pictures on documents) should be readable.

If any clarification is needed, please contact VPRS on: [email protected], or via postal address:VPRSPo Box 195192500 CM, The HagueThe NetherlandsContact telephone number: +31(0)70 515 95 55

This question is relevant for the sections on both participation and reparations. If the victim knows of witnesseswho can support the claims in relation to the alleged crime(s) and/or harm, those names should be listed, togetherwith the relevant contact details. Please note that this information should only be provided with the consent ofthe witness(es).


Page 3: information specific to REPARATIONSTHIS INFORMATION IS ONLY TO BE COMPLETED IF THE VICTIM HAS TICKED THE BOX ON THE FIRST PAGE FORREPARATIONS OR PARTICPATION/REPARATIONS

Please ensure that the information is consistent with that provided on Page 1 of the form.

The ICC recognizes different types of harm that a victim suffers as a result of crimes that the ICC deals with. Thesecrimes can cause physical suffering to a person's body. They can also cause emotional suffering or psychological ormental harm, by which a person's mind is affected because of what she or he has experienced or witnessed.

There could also be material harm, such as where property is damaged or lost as the result of the crime, includingthe victim’s home or other property. In this section information should be provided about the exact nature of theinjury, damage, or suffering that the victim experienced as a result of the actions or events that the victimdescribed on the first page of the form.

Please tick the box or boxes that correspond to the harm that the victim suffered as a result of the crimes allegedlycommitted. Please note that multiple boxes may be ticked. Once ticked, the victim need only answer the follow upquestions below that correspond to the box(es) ticked. For example, if the victim suffered mental pain and anguishand loss of or damage to property, the victim should tick both relevant boxes in question 1 and also fill in sub-questions: B. Mental Pain and Anguish, and C. Loss of or damage to property.

If the box for physical injuries was ticked in question 1, this sub-question should be answered detailing the specificphysical injury that resulted from the crimes allegedly committed (and reported on the first page of theapplication form).

Physical injuries may include anything that results in physical suffering to a person’s body, for example, gunshotwounds, bruised or broken bones, stab wounds, loss of limbs or limb functions, organ failure, disease contraction,injuries as a result of sexual violence, or any other form of physical injury.

Please provide the number of any previously submitted application(s) in the present case before the ICC or in theAl Mahdi case, if known. This information helps the ICC to trace the victim’s details, if the victim has previouslysubmitted an application. This does not include information pertaining to national proceedings.


If the box for mental pain and anguish was ticked in question 1, this sub-question should be answered by tickingwhat form of mental pain and anguish corresponds with the harm that the victim suffered in relation to thecrimes allegedly committed (and reported on page one).

Each of the four options presented (Emotional problems; Mental problems; Physical reactions and behaviouralchanges; Pain, complaints and/or concerns related to experiences of sexual violence) contains examples to helpthe victim choose the proper corresponding harm. There is also a space next to each of the tick boxes for thevictim to add further details should they so wish. This is not required.

If the box for property loss was ticked in question 1, this sub-question should be answered by ticking the type ofproperty loss that corresponds with the loss that the victim suffered in relation to the crimes allegedlycommitted (and reported on page one).

Each of the five options presented (Homes; Land; Personal property, including household goods; Animals;Other) are examples to help the victim choose the proper corresponding harm. There is also a space next to eachof the tick boxes for the victim to add further detail should they so wish. This is not required.

Should none of the examples correspond with the type of property lost by the victim, the victim should tick the“other” box and explain the specific type of property loss suffered in the free space available.

If the box for other harm or damage was ticked in question 1, this sub-question should be answered by ticking thebox that corresponds with the other type of harm or damage suffered by the victim in relation to the crimesallegedly committed (and reported on page one).

Each of the four options presented (Loss of income, salaries, or other support connected to livelihood; Loss ofsavings at banks, stocks and other securities; Legal rights; Other) are examples to help the victim choose theproper corresponding harm. There is also a space next to each of the tick boxes for the victim to add further detailshould they so wish. This is not required.

Should none of the examples correspond with the type of other harm or damage suffered by the victim, the victimshould tick the “other” box and explain the specific type of other harm or damage suffered in the free spaceavailable.


As mentioned above, reparations can be anything that can help the victim to repair the harm suffered. This caninclude compensation, various forms of assistance, restitution of property, and/or symbolic or moral measuressuch as apologies and monuments commemorating victims.

For question 2, the victim is invited to tick the box or boxes that correspond with the type of reparations that thevictim wishes to claim. Please note that reparations will only be awarded in the event of a conviction at the closeof trial.

It should also be noted that the ICC judges will ultimately decide on how and what type of reparations will beawarded including whether they be individual, collective or both. Thus, the victim may not necessarily receive thereparation award requested.

In relation to the specific options presented in Question 2 (above), the option for compensation should be ticked ifthe victim considers financial compensation as the most appropriate award for the harm suffered. It may also beticked if property that was lost cannot be replaced and only compensation can contribute to repairing the harm.

Return of specific property lost should be ticked if the victim has alleged property loss as a form of harm sufferedand the specific property lost cannot be replaced or compensated for and is still thought to remain in thepossession of the accused person.

Physical or psychological treatment should be ticked if the victim continues to suffer from any form of mentalpain and anguish and would benefit from medical treatment.

Other form of reparations should be ticked if none of the above corresponds with the type of award that thevictim considers most appropriate to address and repair the harm suffered. If this box is ticked, the victim shouldspecify in the space provided what type of reparations award would be most appropriate.

The ICC Trust Fund for Victims is a body that may make financial resources available for reparations awards issuedby the ICC Judges when the convicted persons are unable to pay the awards themselves.

The awards “complemented” by the Trust Fund are typically collective because the resources available to the TrustFund for all of the cases before the ICC are limited. Thus, in relation to question 3, the victim is invited to considerwhat other type of awards may be beneficial to the victim, the victim’s family and/or the victim’s community.

Examples may include: education grants, school or hospital construction, vocational training, micro-loanaccessibility, or any other income generating activity. The victim should indicate in the space provided whatadditional forms of reparation would be appropriate.


In this question, the victim is invited to consider whether any community development or collective projectsprovided by other organizations or entities for the purpose of humanitarian aid or development have benefittedthe victim and the victim’s community. If the victim is aware of projects that have positively impacted on thecommunity, the victim should tick ‘yes’ in the box provided and specify (to the extent possible) the organizationresponsible and the (type of) persons who benefitted from the project in the community.

In this question, the victim is invited to consider whether any community development or collective projectsprovided by other organizations or entities for the purpose of humanitarian aid or development have negativelyimpacted on the victim and the victim’s community. If the victim is aware of projects that have negativelyimpacted on the community, the victim should tick ‘yes’ in the box provided and specify (to the extent possible)the organization responsible and the (type of) persons who benefitted from the project in the community, as wellas the reasons why the victim perceives the negative impact.

Before signing the form, the victim should either read the form in its entirety/ or have the personassisting the victim read it back to him/her to ensure the accuracy of the information provided.

After the form is signed by the victim, the form should not be altered in any way (for example, byadding or removing information). If the victim wishes to modify his/her declaration, he/she shouldcontact the VPRS which will provide a specific form to that effect.

Please note that by signing this document, the information provided in this form will be transmitted to the ICC’s TrustFund for Victims so that they may consider how best to use their limited resources to complement reparation awards inthe event of a conviction. The Trust Fund for Victims is also bound by duties of confidentiality and will not share thevictim’s personal information with the public unless the Trust Fund receive prior consent from the victim(s) concerned.

Please also note that any supplementary documents related specifically to verifying reparation claims that are notreadily available at the time the victim completes the form are not necessary to be produced yet for the validity of theform. Should the victim be admitted to participate in proceedings, the victim will be represented by a legalrepresentative who can assist the victim in producing the necessary documentation relating to the verification ofreparations claims should they be necessary.

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