PHASE 1: EXPRESSION OF INTEREST FORM

 

PHASE 1: EXPRESSION OF INTEREST FORM

Reparatory Justice for IC3 Black and Mixed-Black People
(Form to be completed and submitted to a trusted Black-led organisation. Do not return to The Reparation Nation Limited.)

This form is anonymous. No names or contact details are required.

1. I declare that I identify as:

☐ Black (IC3)

☐ Mixed-Black (e.g. Mulatto, Quadroon, Octoroon, Remnaroon)

☐ Other (related to Black ancestry – optional to specify): ______________________

2. My heritage is primarily from:

☐ Diaspora (Caribbean, Americas, Afro-Europe, etc.)

☐ Africa (Continental lineage with Tribe/Clan/Sub-clan)

☐ Both / Not Sure

3. I am expressing interest through this Black-led organisation:

Organisation Name (optional): ______________________________________

4. Optional Comment or Statement:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

FOR ORGANISATIONAL USE ONLY

Date Received: __________________

Organisation Code (if applicable): __________________

Initials of Receiving Organiser (optional): _____________

INSTRUCTIONS:
- This form should be completed in private.
- It may be folded or sealed before submission.
- No copies are to be made without the person’s verbal or written permission.

THIS IS PHASE 1 ONLY — IT DOES NOT GRANT ACCESS TO FUNDS OR SERVICES YET.
It signifies your interest and supports the structure of reparatory justice.

This form is collected by trusted Black-led organisations and not processed by individuals or the central entity.
The Reparation Nation Limited is constructing the Black organisation and is not processing these forms directly.
Contact: TheReparationNation@gmail.com

 

IC3 Black Ancestry Groupings for Reparatory Justice – Visual Reference