Schedule-1
(Relating to Sub-rule (1), or (2) of Rule-3)
Format of the Complaint
Submitted to …….
Complaint
I ………(victim) aged……years, resident of ………district
…….Municipality/Village Development Committee, Ward No….., submit this
complaint letter requesting necessary action against……., aged…….resident of
……district …….Municipality/Village Development Committee, Ward
No.,…for committing an offence of domestic violence upon mentioning the
following details.
1. Whether domestic violence has taken place or going to take place or is
taking place:
(a) Place,
(b) Date,
(c) Time,
2. Nature of domestic violence:
(a) Physical torture,
(b) Mental torture,
(c) Sexual torture,
(d) Financial torture,
(e) Others
3. Consequence of domestic violence on victim.
4. If anyone other than the victim has seen or knowledge of domestic violence
his/her name and address:
(a)
(b)
(c)
5. Evidence, if any:
6. If complaint is lodged in any other Complaint Hearing Body, name of such
body and date of such complaint.
7. The statement mentioned above is true and correct, if proved otherwise I
shall abide by law.
Complainant’s Name:
Signature:
Name:
Address:
Date: