1. First and last name
2. Present Address
3. Are you a legal resident or citizen of another country other than Iran?
4. How old were you when you were arrested?
5. What was your occupation when you were arrested?
6. Date of arrest
7. Location of arrest
8. People responsible for your arrest
9. Did the responsible people for your arrest showed you any legal documents authorizing them to do so?
10. What was your alleged crime?
11. Who were the government authorities at the time of your arrest?
• President
• The minister of justice
• The prison warden
• The judge
• The prison guards
• Interrogators and the branch of investigation
12. Were you allowed to be interrogated without covering your eyes?
13. Were you under physical and mental torture during interrogation?
14. Please explain the types of torture that were used on you during your interrogation.
15. Have you been a witness of performing torture on some one else?
16. How many times were you under torture?
17. Was participation in Islamic religious ceremonies such as prayers, and group praying obligatory for you?
18. Was hearing other political prisoners’ confessions obligatory for you?
19. Was participation in political and ideological classes at the prison obligatory for you?
20. Were you tortured if you did not agree to participate in Islamic religious ceremonies, political and ideological classes, and participation in other political prisoners’ interrogations?
21. Have you been arrested and detained as political prisoner more than one time?
22. Did you go to the court after your interrogations were completed?
23. Were you assigned a court appointed counselor for your defense?

If you were assigned a counselor, did he/she have access to your allegedly criminal files?
24. Were you able to attend the court without having your eyes covered?
25. What was the length of your trial?
26. Was the time to serve as a political prisoner communicated to you by the court?
27. Please give us the names and locations of the prisons you have been detained.
28. Were any of your relatives or friends in prison as political prisoners?

First name and last name of these friends and relatives
What were they accused of
Did they go to court for this accusation?
Were they assigned a counsel for their defense?
Were any of them executed?
The name of the people executed and the date of execution
Were the bodies of these people released to their relatives?
If so where are they buried?
29. Were you released from prison right after your prison term was completed?
30. If you were not released at the date set by court, how long did you stay in prison in addition to your prison term?
31. Did you have to present any kind of collateral to be released form the prison after your prison term was completed?

Type of collateral?
32. Length of time for the collateral to be in effect

If the collateral was financial, what was the amount?
33. Have you been under interrogation after your prison term was completed?

For how long?
At what intervals?
34. Did any of the Islamic government organizations or intelligence agencies imposed any barriers on you for your continuation of education in the higher educational institutions, or pursuit of a profession?
35. Were you requested to cooperate with any of the Islamic government's intelligence agencies after your release from the prison?
36. Did the Islamic government impose a deterrent for your travel outside Iran?

For how long?
37. Are you willing to cooperate with MEHR Foundation for claims against those who are violating human rights in Iran?
38. Are you willing to be a witness in the courts that investigate the violators of human rights in Iran?
39. Are you in possession of any documents, which can be used against the people responsible for violation of human rights in Iran?
40. Please add any other issues you would like to discuss in addition to the information provided above.

Please send your completed form through either email or regular mail to the following addresses

MEHR IRAN
P.O. Box 2037
P.V.P., CA 90275
E-mail: unplan@usa.net