| A. Complainant Details: |
| Name* |
: |
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| Relationship with the victim* |
: |
Parent
Relative
Friend
NGO
Self
Others
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| Gender* |
: |
Male
Female
Others
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| Address* |
: |
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| Police Station* |
: |
|
| State* |
: |
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| District* |
: |
|
| Pin* |
: |
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| Mobile* |
: |
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| Land Line |
: |
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| Email |
: |
|
| |
| B. Victim Details: |
| Number of Victim/Victims* |
: |
|
 |
|
| C. Alleged violator details |
| Name* |
: |
|
| Gender* |
: |
Male
Female
Others
|
| Address |
: |
|
| Police Station |
: |
|
| State |
: |
|
| District |
: |
|
| Pin |
: |
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| Mobile |
: |
|
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| D. Incident Details* |
| Date of Incident* |
: |
|
| Time of Incident* |
: |
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Place of Incident
(with Village/Ward/
Block/District details)* |
: |
|
| |
E. FIR Details(if lodged):*
|
with copy of FIR
(upload FIR scaned copy)* |
: |
|
| Details of Incident* |
: |
|
| I do hereby declare that the complaint has not been filed before any other Commission/Court earlier. |
| |
| *Marked fields are mandatory |
|
upload Scaned copy of signature*
|
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