A/HRC/36/40 Annex VIII Inspection Panel Form — Sample form (More information about the Inspection Panel Form is available at: http://ewebapps.worldbank.org/apps/ip/Documents/Guidelines_How%20to%20File_for_w eb.pdf) To: Executive Secretary, the Inspection Panel 1818 H Street NW, MSN 10-1007,Washington, DC 20433, USAEmail: ipanel@worldbank.org or the appropriate World Bank Country/Regional Office • We [insert names] live and/or represent others who live in the area known as [insert name of area]. • Our addresses are attached. • We have suffered, or are likely to suffer, harm as a result of the World Bank’s failures or omissions in the [insert name and/or brief description of the project or program] located in [insert location/country]. • [Describe the damage or harm you are suffering or are likely to suffer from the project or program.] • [List (if known) the World Bank’s operational polices you believe have not been observed.] • We have complained to World Bank staff on the following occasions [list dates] by [explain how the complaint was made]. No response was received, [or] we believe that the response received is not satisfactory as it does not answer or solve our problems for the following reasons: • We request the Inspection Panel recommend to the World Bank’s Executive Directors that an investigation of these matters be carried out. Signatures: Date: Contact address, telephone number, fax number, and e-mail address: List of attachments We [do/do not] authorize you to disclose our identities 47