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Home / Bare Acts / Central Acts and Rules / Criminal Laws / Protection of Women From Domestic Violence Act,2005 / Protection of Women From Domestic Violence Rules,2006

Protection of Women From Domestic Violence Rules,2006

The Protection Of Women From Domestic Violence Rules, 2006

Published vide Notification G.S.R. 644(E), dated 17.10.2006 and published in the Gazette of India, Extraordinary, Part 2, Section 3(i), dated 17.10.2006.

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In exercise of the powers conferred by section 37 of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005), the Central Government hereby makes the following rules, namely:—

  1. Short title and commencement .—(1) These rules may be called The Protection of Women from Domestic Violence Rules, 2006.

(2) They shall come into force on the 26th day of October, 2006.

  1. Definitions .—In these rules, unless the context otherwise requires,—

(a) “Act” means the Protection of Women from Domestic Violence Act, 2005 (43 of 2005);

(b) “complaint” means any allegation made orally or in writing by any person to the Protection Officer;

(c) “Counsellor” means a member of a service provider competent to give counselling under sub-section (1) of section 14;

(d) “Form” means a form appended to these rules;

(e) “section” means a section of the Act;

(f) words and expressions used and not defined in these rules but defined in the Act shall have the meanings respectively assigned to them in the Act.

  1. Qualifications and experience of Protection Officers .—(1) The Protection Officers appointed by the State Government may be of the Government or members of non-governmental organisations:

Provided that preference shall be given to women.

(2) Every person appointed as Protection Officer under the Act shall have at least three years experience in social sector.

(3) The tenure of a Protection Officer shall be a minimum period of three years.

(4) The State Government shall provide necessary office assistance to the Protection Officer for the efficient discharge of his or her functions under the Act and these rules.

  1. Information to Protection Officers .—(1) Any person who has reason to believe that an act of domestic violence has been, or is being, or is likely to be committed may give information about it to the Protection Officer having jurisdiction in the area either orally or in writing.

(2) In case the information is given to the Protection Officer under sub-rule (1) orally, he or she shall cause it to be reduced to in writing and shall ensure that the same is signed by the person giving such information and in case the informant is not in a position to furnish written information the Protection Officer shall satisfy and keep a record of the identity of the person giving such information.

(3) The Protection Officer shall give a copy of the information recorded by him immediately to the informant free of cost.

  1. Domestic incident reports .—(1) Upon receipt of a complaint of domestic violence, the Protection Officer shall prepare a domestic incident report in Form I and submit the same to the Magistrate and forward copies thereof to the Police Officer in charge of the police station within the local limits of jurisdiction of which the domestic violence alleged to have been committed has taken place and to the service providers in that area.

(2) Upon a request of any aggrieved person, a service provider may record a domestic incident report in Form I and forward a copy thereof to the Magistrate and the Protection Officer having jurisdiction in the area where the domestic violence is alleged to have taken place.

  1. Applications to the Magistrate .—(1) Every application of the aggrieved person under section 12 shall be in Form II or as nearly as possible thereto.

(2) An aggrieved person may seek the assistance of the Protection Officer in preparing her application under sub-rule (1) and forwarding the same to the concerned Magistrate.

(3) In case the aggrieved person is illiterate, the Protection Officer shall read over the application and explain to her the contents thereof.

(4) The affidavit to be filed under sub-section (2) of section 23 shall be filed in Form III.

(5) The applications under section 12 shall be dealt with and the orders enforced in the same manner laid down under section 125 of the Code of Criminal Procedure, 1973 (2 of 1974).

  1. Affidavit for obtaining ex parte orders of Magistrate .—Every affidavit for obtaining ex parte order under sub-section (2) of section 23 shall be filed in Form III.
  2. Duties and functions of Protection Officers .—(1) It shall be the duty of the Protection Officer—

(i) to assist the aggrieved person in making a complaint under the Act, if the aggrieved person so desires;

(ii) to provide her information on the rights of aggrieved persons under the Act as given in Form IV which shall be in English or in a vernacular local language;

(iii) to assist the person in making any application under section 12, or sub-section (2) of section 23 or any other provision of the Act or the rules made thereunder;

(iv) to prepare a “Safety Plan” including measures to prevent further domestic violence to the aggrieved person, in consultation with the aggrieved person in Form V, after making an assessment of the dangers involved in the situation and on an application being moved under section 12;

(v) to provide legal aid to the aggrieved person, through the State Legal Aid Services Authority;

(vi) to assist the aggrieved person and any child in obtaining medical aid at a medical facility including providing transportation to get the medical facility;

(vii) to assist in obtaining transportation for the aggrieved person and any child to the shelter;

(viii) to inform the service providers registered under the Act that their services may be required in the proceedings under the Act and to invite applications from service providers seeking particulars of their members to be appointed as Counsellors in proceedings under the Act under sub-section (1) of section 14 or Welfare Experts under section 15;

(ix) to scrutinise the applications for appointment as Counsellors and forward a list of available Counsellors to the Magistrate;

(x) to revise once in three years the list of available Counsellors by inviting fresh applications and forward a revised list of Counsellors on the basis thereof to the concerned Magistrate;

(xi) to maintain a record and copies of the report and documents forwarded under sections 9, 12, 20, 21, 22, 23 or any other provisions of the Act or these rules;

(xii) to provide all possible assistance to the aggrieved person and the children to ensure that the aggrieved person is not victimised or pressurised as a consequence of reporting the incidence of domestic violence;

(xiii) to liaise between the aggrieved person or persons, police and service provider in the manner provided under the Act and these rules;

(xiv) to maintain proper records of the service providers, medical facility and shelter homes in the area of his jurisdiction.

(2) In addition to the duties and functions assigned to a Protection Officer under clauses (a) to (h) of sub-section (1) of section 9, it shall be the duty of every Protection Officer—

(a) to protect the aggrieved persons from domestic violence, in accordance with the provisions of the Act and these rules;

(b) to take all reasonable measures to prevent recurrence of domestic violence against the aggrieved person, in accordance with the provisions of the Act and these rules.

  1. Action to be taken in cases of emergency .—If the Protection Officer or a service provider receives reliable information through e-mail or a telephone call or the like either from the aggrieved person or from any person who has reason to believe that an act of domestic violence is being or is likely to be committed and in a such an emergency situation, the Protection Officer or the service provider, as the case may be, shall seek immediate assistance of the police who shall accompany the Protection Officer or the service provider, as the case may be, to the place of occurrence and record the domestic incident report and present the same to the Magistrate without any delay for seeking appropriate orders under the Act.
  2. Certain other duties of the Protection Officers .—(1) The Protection Officer, if directed to do so in writing, by the Magistrate shall—

(a) conduct a home visit of the shared household premises and make preliminary enquiry if the Court requires clarification, in regard to granting ex parte interim relief to the aggrieved person under the Act and pass an order for such home visit;

(b) after making appropriate inquiry, file a report on the emoluments, assets, bank accounts or any other documents as may be directed by the Court;

(c) restore the possession of the personal effects including gifts and jewellery of the aggrieved person and the shared household to the aggrieved person;

(d) assist the aggrieved person to regain custody of children and secure rights to visit them under his supervision as may be directed by the Court;

(e) assist the Court in enforcement of orders in the proceedings under the Act in the manner directed by the Magistrate, including orders under section 12, section 18, section 19, section 20, section 21 or section 23 in such manner as may be directed by the Court;

(f) take the assistance of the police, if required, in confiscating any weapon involved in the alleged domestic violence.

(2) The Protection Officer shall also perform such other duties as may be assigned to him by the State Government or the Magistrate in giving effect to the provisions of the Act and these rules from time to time.

(3) The Magistrate may, in addition to the orders for effective relief in any case, also issue directions relating general practice for better handling of the cases, to the Protection Officers within his jurisdiction and the Protection Officers shall be bound to carry out the same.

  1. Registration of service providers .—(1) Any voluntary association registered under the Societies Registration Act, 1860 (21 of 1860) or a company registered under the Companies Act, 1956 (1 of 1956) or any other law for time being in force with the objective of protecting the rights and interests of women by any lawful means including providing of legal aid, medical, financial or other assistance and desirous of providing service as a service provider under the Act shall make an application under sub-section (1) of section 10 for registration as service provider in Form VI to the State Government.

(2) The State Government shall, after making such enquiry as it may consider necessary and after satisfying itself about the suitability of the applicant, register it as a service provider and issue a certificate of such registration:

Provided that no such application shall be rejected without giving the applicant an opportunity of being heard.

(3) Every association or company seeking registration under sub-section (1) of section 10 shall possess the following eligibility criteria, namely:—

(a) It should have been rendering the kind of services it is offering under the Act for at least three years before the date of application for registration under the Act and these rules as a service provider.

(b) In case an applicant for registration is running a medical facility, or a psychiatric counselling centre, or a vocational training institution, the State Government shall ensure that the applicant fulfils the requirements for running such a facility or institution laid down by the respective regulatory authorities regulating the respective professions or institutions.

(c) In case an applicant for registration is running a shelter home, the State Government shall, through an officer or any authority or agency authorised by it, inspect the shelter home, prepare a report and record its finding on the report, detailing that—

(i) the maximum capacity of such shelter home for intake of persons seeking shelter;

(ii) the place is secure for running a shelter home for women and that adequate security arrangements can be put in place for the shelter home;

(iii) the shelter home has a record of maintaining a functional telephone connection or other communication media for the use of the inmates;

(3) The State Government shall provide a list of service providers in the various localities to the concerned Protection Officers and also publish such list in newspapers or on its website.

(4) The Protection Officer shall maintain proper records by way of maintenance of registers duly indexed, containing the details of the service providers.

  1. Means of service of notices .—(1) The notices for appearance in respect of the proceedings under the Act shall contain the names of the person alleged to have committed domestic violence, the nature of domestic violence and such other details which may facilitate the identification of person concerned.

(2) The service of notices shall be made in the following manner, namely:—

(a) The notices in respect of the proceedings under the Act shall be served by the Protection Officer or any other person directed by him to serve the notice, on behalf of the Protection Officer, at the address where the respondent is stated to be ordinarily residing in India by the complainant or aggrieved person or where the respondent is stated to be gainfully employed by the complainant or aggrieved person, as the case may be.

(b) The notice shall be delivered to any person in charge of such place at the moment and in case of such delivery not being possible it shall be pasted at a conspicuous place on the premises.

(c) For serving the notices under section 13 or any other provision of the Act, the provisions under Order V of the Civil Procedure Code, 1908 (5 of 1908) or the provisions under Chapter VI of the Code of Criminal Procedure, 1973 (2 of 1974) as far as practicable may be adopted.

(d) Any order passed for such service of notices shall entail the same consequences, as an order passed under Order V of the Civil Procedure Code, 1908 (5 of 1908) or Chapter VI of the Code of Criminal Procedure, 1973 (2 of 1974) respectively, depending upon the procedure found efficacious for making an order for such service under section 13 or any other provision of the Act and in addition to the procedure prescribed under the Order V or Chapter VI, the Court may direct any other steps necessary with a view to expediting the proceedings to adhere to the time limit provided in the Act.

(3) On a statement on the date fixed for appearance of the respondent, or a report of the person authorised to serve the notices under the Act, that service has been effected appropriate orders shall be passed by the Court on any pending application for interim relief, after hearing the complainant or the respondent, or both.

(4) When a protection order is passed restraining the respondent from entering the shared household or the respondent is ordered to stay away or not to contact the petitioner, no action of the aggrieved person including an invitation by the aggrieved person shall be considered as waiving the restraint imposed on the respondent, by the order of the Court, unless such protection order is duly modified in accordance with the provisions of sub-section (2) of section 25.

  1. Appointment of Counsellors .—(1) A person from the list of available Counsellors forwarded by the Protection Officer, shall be appointed as a Counsellor, under intimation to the aggrieved person.

(2) The following persons shall not be eligible to be appointed as Counsellors in any proceedings, namely:—

(i) any person who is interested or connected with the subject-matter of the dispute or is related to any one of the parties or to those who represent them unless such objection is waived by all the parties in writing.

(ii) any legal practitioner who has appeared for the respondent in the case or any other suit or proceedings connected therewith.

(3) The Counsellors shall as far as possible be women.

  1. Procedure to be followed by Counsellors .—(1) The Counsellor shall work under the general supervision of the Court or the Protection Officer or both.

(2) The Counsellor shall convene a meeting at a place convenient to the aggrieved person or both the parties.

(3) The factors warranting counselling shall include the factor that the respondent shall furnish an undertaking that he would refrain from causing such domestic violence as complained by the complainant and in appropriate cases an undertaking that he will not try to meet, or communicate in any manner through letter or telephone, electronic mail or through any medium except in the counselling proceedings before the Counsellor or as permissible by law or order of a Court of competent jurisdiction.

(4) The Counsellor shall conduct the counselling proceedings bearing in mind that the counselling shall be in the nature of getting an assurance, that the incidence of domestic violence shall not get repeated.

(5) The respondent shall not be allowed to plead any counter justification for the alleged act of domestic violence in counselling the fact that and any justification for the act of domestic violence by the respondent is not allowed to be a part of the counselling proceeding should be made known to the respondent, before the proceedings begin.

(6) The respondent shall furnish an undertaking to the Counsellor that he would refrain from causing such domestic violence as complained by the aggrieved person and in appropriate cases an undertaking that he will not try to meet, or communicate in any manner through letter or telephone, e-mail, or through any other medium except in the counselling proceedings before the Counsellor.

(7) If the aggrieved person so desires, the Counsellor shall make efforts of arriving at a settlement of the matter.

(8) The limited scope of the efforts of the Counsellor shall be to arrive at the understanding of the grievances of the aggrieved person and the best possible redressal of her grievances and the efforts shall be to focus on evolving remedies or measures for such redressal.

(9) The Counsellor shall strive to arrive at a settlement of the dispute by suggesting measures for redressal of grievances of the aggrieved person by taking into account the measures or remedies suggested by the parties for counselling and reformulating the terms for the settlement, wherever required.

(10) The Counsellor shall not be bound by the provisions of the Indian Evidence Act, 1872 (1 of 1872) or the Code of Civil Procedure, 1908 (5 of 1908), or the Code of Criminal Procedure, 1973 (2 of 1974), and his action shall be guided by the principles of fairness and justice and aimed at finding way to bring an end to domestic violence to the satisfaction of the aggrieved person and in making such an effort the Counsellor shall give due regard to the wishes and sensibilities of the aggrieved person.

(11) The Counsellor shall submit his report to the Magistrate as expeditiously as possible for appropriate action.

(12) In the event the Counsellor arrives at a resolution of the dispute, he shall record the terms of settlement and get the same endorsed by the parties.

(13) The Court may, on being satisfied about the efficacy of the solution and after making a preliminary enquiry from the parties and after recording reasons for such satisfaction, which may include undertaking by the respondents to refrain from repeating acts of domestic violence, admitted to have been committed by the respondents, accept the terms with or without conditions.

(14) The Court shall, on being so satisfied with the report of counselling, pass an order, recording the terms of the settlement or an order modifying the terms of the settlement on being so requested by the aggrieved person, with the consent of the parties.

(15) In cases, where a settlement cannot be arrived at in the counselling proceedings, the Counsellor shall report the failure of such proceedings to the Court and the Court shall proceed with the case in accordance with the provisions of the Act.

(16) The record of proceedings shall not be deemed to be material on record in the case on the basis of which any inference may be drawn or an order may be passed solely based on it.

(17) The Court shall pass an order under section 25, only after being satisfied that the application for such an order is not vitiated by force, fraud or coercion or any other factor and the reasons for such satisfaction shall be recorded in writing in the order, which may include any undertaking or surety given by the respondent.

  1. Breach of Protection Orders .—(1) An aggrieved person may report a breach of protection order or an interim protection order to the Protection Officer.

(2) Every report referred to in sub-rule (1) shall be in writing by the informant and duly signed by her.

(3) The Protection Officer shall forward a copy of such complaint with a copy of the protection order of which a breach is alleged to have taken place to the concerned Magistrate for appropriate orders.

(4) The aggrieved person may, if she so desires, make a complaint of breach of protection order or interim protection order directly to the Magistrate or the Police, if she so chooses.

(5) If, at any time after a protection order has been breached, the aggrieved person seeks his assistance, the Protection Officer shall immediately rescue her by seeking help from the local police station and assist the aggrieved person to lodge a report to the local police authorities in appropriate cases.

(6) When charges are framed under section 31 or in respect of offences under section 498-A of the Indian Penal Code (45 of 1860), or any other offence not summarily triable, the Court may separate the proceedings for such offences to be tried in the manner prescribed under Code of Criminal Procedure, 1973 (2 of 1974) and proceed to summarily try the offence of the breach of protection order under section 31, in accordance with the provisions of Chapter XXI of the Code of Criminal Procedure, 1973 (2 of 1974).

(7) Any resistance to the enforcement of the orders of the Court under the Act by the respondent or any other person purportedly acting on his behalf shall be deemed to be a breach of protection order or an interim protection order covered under the Act.

(8) A breach of a protection order or an interim protection order shall immediately be reported to the local police station having territorial jurisdiction and shall be dealt with as a cognizable offence as provided under sections 31 and 32.

(9) While enlarging the person on bail arrested under the Act, the Court may, by order, impose the following conditions to protect the aggrieved person and to ensure the presence of the accused before the Court, which may include—

(a) an order restraining the accused from threatening to commit or committing an act of domestic violence;

(b) an order preventing the accused from harassing, telephoning or making any contact with the aggrieved person;

(c) an order directing the accused to vacate and stay away from the residence of the aggrieved person or any place she is likely to visit;

(d) an order prohibiting the possession or use of firearm or any other dangerous weapon;

(e) an order prohibiting the consumption of alcohol or other drugs;

(f) any other order required for protection, safety and adequate relief to the aggrieved person.

  1. Shelter to the aggrieved person .—(1) On a request being made by the aggrieved person, the Protection Officer or a service provider may make a request under section 6 to the person in charge of a shelter home in writing, clearly stating that the application is being made under section 6.

(2) When a Protection Officer makes a request referred to in sub-rule (1), it shall be accompanied by a copy of the domestic incident report registered, under section 9 or under section 10:

Provided that shelter home shall not refuse shelter to an aggrieved person under the Act, for her not having lodged a domestic incident report, prior to the making of request for shelter in the shelter home.

(3) If the aggrieved person so desires, the shelter home shall not disclose the identity of the aggrieved person in the shelter home or communicate the same to the person complained against.

  1. Medical facility to the aggrieved person .—(1) The aggrieved person or the Protection Officer or the service provider may make a request under section 7 to a person-in-charge of a medical facility in writing, clearly stating that the application is being made under section 7.

(2) When a Protection Officer makes such a request, it shall be accompanied by a copy of the domestic incident report:

Provided that the medical facility shall not refuse medical assistance to an aggrieved person under the Act, for her not having lodged a domestic incident report, prior to making a request for medical assistance or examination to the medical facility.

(3) If no domestic incident report has been made, the person-in-charge of the medical facility shall fill in Form I and forward the same to the local Protection Officer.

(4) The medical facility shall supply a copy of the medical examination report to the aggrieved person free of cost.

FORM I

[See rules 5(1) and (2) and 17(3)]

Domestic Incident Report Under Sections 9(B) And 37(2)(C) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

  1. Details of the complainant/aggrieved person:

(1) Name of the complainant/aggrieved person:

(2) Age:

(3) Address of the shared household:

(4) Present Address:

(5) Phone Number, if any:

  1. Details of Respondents:
Sl. No. Name Relationship with the aggrieved person Address Telephone No., if any
 

 

  1. Details of children, if any, of the aggrieved person:

(a) Number of children:

(b) Details of children:

Name Age Sex With whom at present residing
 
  1. Incidents of domestic violence :
Sl. No. Date, place and time of violence Person who caused domestic violence Types of violence Remarks
Physical violence
Causing hurt of any kind, please specify

 

(i) Sexual violence
Please tick mark [√] the column applicable
❑ Forced sexual intercourse
❑ Forced to watch pornography or other obscene material
❑ Forcibly using you to entertain others
❑ Any other act of sexual nature, abusing, humiliating, degrading or otherwise violative of your dignity (please specify details in the space provided below)
(ii) Verbal and emotional abuse
❑ Accusation/aspersion on your character or conduct, etc.
❑ Insult for not bringing dowry, etc.
❑ Insult for not having a male child
❑ Insult for not having any child
❑ Demeaning, humiliating or undermining remarks/statement
❑ Ridicule
❑ Name calling
❑ Forcing you to not attend school, college or any other educational institution
❑ Preventing you from taking up a job
❑ Preventing you from leaving the House
❑ Preventing you from meeting any particular person
❑ Forcing you to get married against your will
❑ Preventing you from marrying a person of your choice
❑ Forcing you to marry a person of his/their own choice
❑ Any other verbal or emotional abuse (please specify in the space provided below)
(iii) Economic violence
❑ Not providing money for maintaining you or your children
❑ Not providing food, clothes, medicine, etc., for you or your children
❑ Forcing you out of the house you live in
❑ Preventing you from accessing or using any part of the house
❑ Preventing or obstructing you from carrying on your employment
❑ Not allowing you to take up an employment
❑ Non-payment of rent in case of a rented accommodation
❑ Not allowing you to use clothes or articles of general household use
❑ Selling or pawing your stridhan or any other valuables without informing you and without your consent
❑ Forcibly taking away your salary, income or wages, etc.
❑ Disposing your stridhan
❑ Non-payment of other bills such as electricity, etc.
❑ Any other economic violence (please specify in the space provided below)
(iv) Dowry related harassment
❑ Demands for dowry made, please specify
❑ Any other detail with regard to dowry, please specify
Whether details of dowry items, stridhan, etc., attached with the form
❑ Yes
❑ No
(v) Any other information regarding acts of domestic violence against you or your children

……………………………………….

(Signature or thumb-impression of the complainant/aggrieved person)

  1. List of documents attached
Name of document Date Any other detail
Medico legal certificate
Doctor’s certificate or any other prescription
List of stridhan
Any other document
  1. Order that you need under the Protection of Women from Domestic Violence Act, 2005
Sl. No. Orders Yes/No Any other
(1) (2) (3) (4)
(1) Protection order under section 18
(2) Residence order under section 19
(3) Maintenance order under section 20
(4) Custody order under section 21
(5) Compensation order under section 22
(6) Any other order (specify)
  1. Assistance that you need
Sl. No. Assistance available Yes/No Nature of assistance
(1) (2) (3) (4)
(1) Counsellor
(2) Police assistance
(3) Assistance for initiating criminal proceedings
(4) Shelter home
(5) Medical facilities
(6) Legal aid
  1. Instruction for the Police Officer assisting in registration of a Domestic Incident Report:

Wherever the information provided in this Form discloses an offence under the Indian Penal Code or any other law, the Police Officer shall–

(a) inform the aggrieved person that she can also initiate criminal proceedings by lodging a First Information Report under the Code of Criminal Procedure, 1973 (2 of 1974),

(b) if the aggrieved person does not want to initiate criminal proceedings, then make daily dairy entry as per the information contained in the domestic incident report with a remark that the aggrieved person due to the intimate nature of the relationship with the accused wants to pursue the civil remedies for protection against domestic violence and has requested that on the basis of the information received by her, the matter has been kept pending for appropriate enquiry before registration of an FIR,

(c) if any physical injury or pain being reported by the aggrieved person, offer immediate medical assistance and get the aggrieved person medically examined.

Place ……………………..

Date ………………………

………………………………….

(Counter-signature of Protection Officer/Service provider)

Name ……………………………………….

Address ……………………………………

(Seal)

Copy forwarded to :-

  1. Local Police Station
  2. Service Provider/Protection Officer
  3. Aggrieved person
  4. Magistrate

FORM II

[See rule 6(1)]

Application To The Magistrate Under Section 12 Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

To,

The Court of Magistrate

……………………………………

……………………………………

Application under section …………………… of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005)

SHOWETH:

  1. That the application under section………..of Protection of Women from Domestic Violence Act, 2005 is being filed alongwith a copy of Domestic Incident Report by the :-
(a) Aggrieved person
(b) Protection Officer
(c) Any other person on behalf of the aggrieved person
(tick whichever is applicable)
  1. It is prayed that the Hon’ble Court may take cognizance of the complaint/Domestic Incident Report and pass all/any of the orders, as deemed necessary in the circumstances of the case.

(a) Pass protection orders under section 18 and/or

(b) Pass residence orders under section 19 and/or

(c) Direct the respondent to pay monetary relief under section 20 and/or

(d) Pass orders under section 21 of the act and/or

(e) Direct the respondent to grant compensation or damages under section 22 and/or

(f) Pass such interim orders as the Court deems just and proper

(g) Pass any orders as deems fit in the circumstances of the case

  1. Orders required:

(i) Protection Order under section 18

 Prohibiting acts of domestic violence by granting an injunction against the Respondent/s from repeating any of the acts mentioned in terms of column 4(a)/(b)/(c)/(d)/(e)/(f)/(g) of the application

 Prohibiting Respondent(s) from entering the school/college/workplace

 Prohibiting from stopping you from going to your place of employment

 Prohibiting Respondent(s) from entering the school/college/any other place of your children

 Prohibiting from stopping you from going to your school

 Prohibiting any form of communication by the Respondent with you

 Prohibiting alienation of assets by the Respondent

 Prohibiting operation of joint bank lockers/accounts by the Respondent and allowing the aggrieved person to operate the same

 Directing the Respondent to stay away from the dependants/relatives/any other person of the aggrieved person to prohibit violence against them

 Any other order, please specify …………

(ii) Residence Order under section 19

 An order restraining Respondent(s) from

 Dispossessing or throwing me out from the shared household

 Entering that portion of the shared household in which I reside

 Alienating/disposing/encumbering the shared household

 Renouncing his rights in the shared household

 An order entitling..le continued access to my personal effects

 An order directing Respondent(s) to

* Remove himself from the shared household

* Secure same level of alternate accommodation or pay rent for the same.

 Any other order, please specify ………………………………………………………………………

……………………………………………………………………………………………………………………….

(iii) Monetary reliefs under section 20

Loss of earnings, Amount claimed ___________________________________________
Medical expenses, Amount claimed ___________________________________________
Loss due to destruction/damage or removal of property from the control of the aggrieved person, Amount claimed ___________________________________________
Any other loss or physical or mental injury as specified in clause 10(d), Amount claimed ___________________________________________
Total amount claimed ___________________________________________
Any other order, please specify ___________________________________________

(iv) Monetary reliefs under section 20

Directing the Respondent to pay the following expenses as monetary relief:
Food, clothes, medications and other basic necessities Amount …………………per month
School fees and related expenses Amount …………………per month
Household expenses Amount …………………per month
Any other expenses Amount …………………per month
Total …………………per month
Any other order, please specify ………………………………………………………………………………………………………………………………………………

(v) Custody Order under section 21

Direct the Respondent to hand over the custody of the child or children to the:-

 Aggrieved person

 Any other person on her behalf, details of such person ……………………………………

(vi) Compensation Order under section 22

(vii) Any other order, please specify ……………………………………………………………………………

  1. Details of previous litigation, if any

(a) El Under the Indian Penal Code, sections ………………………………..Pending in the

Court of ………………………………………………………………………………………………………….

El Disposed off, details of relief …………………………………………………………………………..

(b)  Under Code of Criminal Procedure, sections ……………………………Pending in the

Court of ………………………………………………………………………………………………………….

 Disposed off, details of relief …………………………………………………………………………..

(c)  Under the Hindu Marriage Act, 1956, sections ………………………….Pending in the

Court of ………………………………………………………………………………………………………….

 Disposed off, details of relief …………………………………………………………………………..

(d)  Under the Hindu Adoptions and Maintenance Act, 1956, sections ………………….

Pending in the Court of …………………………………………………………………………………..

Disposed off, details of relief …………………………………………………………………………..

(e)  Application for maintenance, under section ……………….under……………………Act

Interim maintenance Rs ………………………………….. p.m.

Maintenance granted Rs …………………………………. p.m.

(f) CD Whether Respondent was sent to Judicial Custody

 For less than a week

 For less than a month

 For more than a month

Specify period …………………………………………………………………………………………………….

(g) Any other order …………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………

Prayer:

It is, therefore, most respectfully prayed that this Hon’ble Court be pleased to grant the relief(s) claimed therein and pass such order or orders or other order as this Hon’ble Court may deem fit and proper under the given facts and circumstances of the case for protecting the aggrieved person from domestic violence and in the interest of justice.

Place ……………………..

Date ………………………

COMPLAINANT/AGGRIEVED PERSON

THROUGH

COUNSEL

Verification

Verified at ………………………..(place) on this………………………..day of………………………..that the contents of Paras. 1 to 12 of the above application are true and correct to the best of my knowledge and nothing material has been concealed therefrom.

DEPONENT

……………………………….

Counter-signature of Protection Officer with date

FORM III

[See rules 6(4) and 7]

Affidavit Under Section 23(2) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

IN THE COURT OF ……………………………..; MM ……………………………..

P/S :…………………………………….

In the matter of

Ms …………………………………………& Others ………………….COMPLAINANT
Versus
Mr …………………………………………& Others ……………………..RESPONDENT

Affidavit

I …………………………………….. W/o Mr……………………………………, R/o…………………………………… D/o Mr ……………………………………….. R/o………………………………………., presently residing at ……………………………………do hereby solemnly affirm and declare on oath as under:

  1. That I am the Applicant in the accompanying application for …………………………………. filed for myself and for my daughter/son.
  2. That I am the natural guardian of ……………………………………………………………………………..
  3. That being conversant with the facts and circumstances of the case I am competent to swear this affidavit.
  4. That the Deponent had been living with the Respondent/s at ………………………………….. since ……………….. to………………..
  5. That the details provided in the present Application for the grant of relief under section(s) ……………….. have been entered into by me/at my instructions.
  6. That the contents of the application have been read over, explained to me in English/Hindi/any other local language (please specify ………………………………….)
  7. That the contents of the said application may be read as part of this affidavit and are not repeated herein for the sake of brevity.
  8. That the applicant apprehends repetition of the acts of domestic violence by the Respondent(s) against which relief is sought in the accompanying application.
  9. That the Respondent has threatened the Applicant that …………………………………………… …………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………..
  10. That the reliefs claimed in the accompanying application are urgent in as much as the applicant would face great financial hardship and would be forced to live under threat of repetition/escalation of acts of domestic violence complained of in the accompanying application by the Respondent(s) if the said reliefs are not granted on an ex partead interim basis.
  11. That the facts mentioned herein are true and correct to the best of my knowledge and belief and nothing material has been concealed there from.

DEPONENT

Verification

Verified at ………………………..(place) on this………………………..day of………………………..20……… that the contents of the above affidavit are correct to the best of my knowledge and belief and no part of it is false and nothing material has been concealed therefrom.

DEPONENT

FORM IV

[See rule 8(1)(ii)]

Information On Rights Of Aggrieved Persons Under The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

  1. If you are beaten up, threatened or harassed in your home by a person with whom you reside in the same house, then you are facing domestic violence. The Protection of Women from Domestic Violence Act, 2005, gives you the right to claim protection and assistance against domestic violence.
  2. You can receive protection and assistance under the Act, if the person(s) with whom you are/were residing in the same house, commits any of the following acts of violence against you or a child in your care and custody-
  3. Physical violence:

For example

(i) Beating,

(ii) Slapping,

(iii) Hitting,

(iv) Biting,

(v) Kicking,

(vi) Punching,

(vii) Pushing,

(viii) Shoving or

(ix) Causing bodily pain or injury in any other manner.

  1. Sexual violence:

For example

(i) Forced sexual intercourse,

(ii) Forces you to look at pornography or any other obscene pictures or material,

(iii) Any act of sexual nature to abuse, humiliate or degrade you, or which is otherwise violative of your dignity or any other unwelcome conduct of sexual nature,

(iv) Child sexual abuse.

  1. Verbal and emotional violence:

For example

(i) Insults,

(ii) Name-calling,

(iii) Accusations on your character or conduct, etc.,

(iv) Insults for not having a male child,

(v) Insults for not bringing dowry, etc.,

(vi) Preventing you or a child in your custody from attending school, college or any other educational institution,

(vii) Preventing you from taking up a job,

(viii) Forcing you to leave your job,

(ix) Preventing you or a child in your custody from leaving the house,

(x) Preventing you from meeting any person in the normal course of events,

(xi) Forcing you to get married when you do not want to marry,

(xii) Preventing you from marrying a person of your own choice,

(xiii) Forcing you to marry a particular person of his/their own choice,

(xiv) Threat to commit suicide,

(xv) Any other verbal or emotional abuse.

  1. Economic violence:

For example

(i) Not providing you money for maintaining you or your children,

(ii) Not providing food, clothes, medicines, etc., for you or your children,

(iii) Stopping you from carrying on your employment or,

(iv) Disturbing you in carrying on your employment,

(v) Not allowing you to take up an employment or,

(vi) Taking away your income from your salary, wages, etc., or,

(vii) Not allowing you to use your salary, wages, etc.,

(viii) Forcing you out of the house you live in,

(ix) Stopping you from accessing or using any part of the house,

(x) Not allowing use of clothes, articles or things of general household use,

(xi) Not paying rent if staying in a rented accommodation, etc.

  1. If an act of domestic violence is committed against you by a person/s with whom you are/were residing in the same house, you can get all or any of the following orders against the person(s)-

(a) Under section 18:

(i) To stop committing any further acts of domestic violence on you or your children;

(ii) To give you the possession of your stridhan, jewellery, clothes, etc.;

(iii) Not to operate the joint bank accounts or lockers without permission of the Court.

(b) Under section 19:

(i) Not to stop you from residing in the house where you were residing with the person/s;

(ii) Not to disturb or interfere with your peaceful enjoyment of residence;

(iii) Not to dispose off the house in which you are residing;

(iv) If your residence is a rented property then either to ensure payment of rent or secure any other suitable alternative accommodation which offers you the same security and facilities as earlier residence.

(v) Not to give up the rights in the property in which you are residing without the permission of the Court.

(vi) Not to take any loan against the house/property in which you are residing or mortgage it or create any other financial liability involving the property.

(vii) Any or all of the following orders for your safety requiring the person/s to.

(c). General Order:

(i) Stop the domestic violence complained/reported.

(d) Special Orders:

(i) Remove himself/stay away from your place of residence or workplace;

(ii) Stop making any attempts to meet you;

(iii) Stop calling you over phone or making any attempts to communicate with you by letter, e-mail, etc.;

(iv) Stop talking to you about marriage or forcing you to meet a particular person of his/their choice for marriage;

(v) Stay away from the school of your child/children, or any other place where you and your children visit;

(vi) Surrender possession of firearms, any other weapon or any other dangerous substance;

(vii) Not to acquire possession of firearms, any other weapon or any other dangerous substance and not to be in possession of any similar article;

(viii) Not to consume alcohol or drugs with similar effect which led to domestic violence in the past;

(ix) Any other measure required for ensuring your or your children’s safety.

(e) An order for interim monetary relief under sections 20 and 22 including–

(i) Maintenance for you or your children;

(ii) Compensation for physical injury including medical expenses;

(iii) Compensation for mental torture and emotional distress;

(iv) Compensation for loss of earning;

(v) Compensation for loss caused by destruction, damage, removal of any property from your possession or control.

Note.-I. Any of the above relief can be granted on an interim basis, as soon as you make a complaint of domestic violence and present your application for any of the relief before the Court.

  1. A complaint of domestic violence made in Form I under the Act is called a “Domestic Incident Report”.
  2. If you are a victim of domestic violence, you have the following rights:

(i) The assistance of a Protection Officer and service providers to inform you about your rights and the relief which you can get under the Act under section 5.

(ii) The assistance of Protection Officer, service providers or the officer in charge of the nearest police station to assist you in registering your complaint and filing an application for relief under sections 9 and 10.

(iii) To receive protection for you and your children from acts of domestic violence under section 18.

(iv) You have right to measures and orders protecting you against the particular dangers or insecurities you or your child are facing.

(v) To stay in the house where you suffered domestic violence and to seek restraint on other persons residing in the same house, from interfering with or disturbing peaceful enjoyment of the house and the amenities facilities therein, by you or your children under section 19.

(vi) To regain possession of your stridhan, jewellery, clothes, articles of daily use and other household goods under section 18.

(vii) To get medical assistance, shelter, counselling and legal aid under sections 6, 7, 9 and 14.

(viii) To restrain the person committing domestic violence against you from contacting you or communicating with you in any manner under section 18.

(ix) To get compensation for any physical or mental injury or any other monetary loss due to domestic violence under section 22.

(x) To file complaint or applications for relief under the Act directly to the Court under sections 12, 18,19, 20, 21,22 and 23.

(xi) To get the copies of the complaint filed by you, applications made by you, reports of any medical or other examination that you or your child undergo.

(xii) To get copies of any statements recorded by any authority in connection with domestic violence.

(xiii) To assistance of the Protection Officer or the Police to rescue you from any danger.

  1. The person providing the form should ensure that the details of all the registered service providers are entered in the manner and space provided below. The following is the list of service providers in the area:
Name of Organisation Service Provided Contact Details

Continue the list on a separate sheet, if necessary ………………………….

FORM V

[See rule 8(1)(iv)]

Safety Plan

  1. When a Protection Officer, Police Officer or any other service provider is assisting the woman in providing details in this form, then details in columns C and D are to be filled in by the Protection Officer, Police Officer or any other service provider, as the case may be, in consultation with the complainant and with her consent.
  2. The aggrieved person in case of approaching the Court directly may herself provide details in columns C and D.
  3. If the aggrieved person leaves columns C and D blank and approaches the Court directly, then details in the said columns are to be provided by the Protection Officer to the Court, in consultation with the complainant and with her consent.
A B C D E
Sl. No. Violence by the Respondent Consequences of violence mentioned in column A suffered by the aggrieved person Apprehensions of the aggrieved person regarding violence mentioned in column A Measures required for safety Orders sought from the Court
1. Physical violence by the Respondent Complainant’s perception that she and her children are at risk of repetition of

physical violence

(a) Repetition

(b) Escalation

(c) Fear of injury

(d) Any other, specify

2. Any sexual act abusing, humiliating or degrading, otherwise violative of your dignity (a) Depression

(b) At risk of repetition of such an act

(c) Facing attempts to commit such acts

(a) Repetition

(b) Escalation

(c) Any other, specify

3. Attempts at strangulation (a) Physical injury

(b) Mental ill health

(c) Any other, specify

(a) Repetition

(b) Any other, specify

4. Beatings to the children (a) Injury to the children

(b) Adverse mental effect of the same on the children

(c) Any other, specify

(a) Risk of repetition

(b) Adverse effect of violent behaviour/environment on the child

5. Threats to commit suicide by the Respondent (a) Violent environment in the house

(b) Threat to safety

(c) Any other, specify

(a) Actually trying to commit the same

(b) Repetition

(c) Any other, specify

6. Attempts to commit suicide by the Respondent (a) Violent environment in the house

(b) Insecurity, anxiety, depression, mental trauma

(c) Any other, specify

(a) Repetition, escalation, aggravation of the same

(b) Mental trauma, pain

(c) Any other, specify

7. Psychological and Emotional abuse of the Complainant like insults, ridicule, name calling, insults for not having a male child, false accusations of unchastity, etc. (a) Depression

(b) Mental trauma, pain

(c) Unsuitable atmosphere for the child/children

(d) Any other, specify

(a) Repetition, escalation, aggravation of the same

(b) Mental trauma, pain

(c) Any other, specify

8. Making verbal threats to cause harm to the aggrieved person/her children/parents/relatives (a) Living in constant fear

(b) Mental trauma, pain

(c) Any other, specify

(a) Respondent may carry out the mentioned threats

(b) Mental trauma, pain

(c) Any other, specify

9. Forcing not to attend school/college/any other educational institution (a) Depression

(b) Mental trauma, pain

(c) Any other, specify

(a) Repetition

(b) Mental trauma, pain

(c) Any other, specify

10. Forcing to get married when do not want to/forcing not to marry a person of choice/forcing to marry a particular person of Respondent/s’ choice (a) Depression

(b) Mental trauma, pain

(c) Fear of being married forcibly

(d) Any other

(a) Repetition

(b) Mental trauma, pain

(c) Any other

11. Threatening to kidnap (a) Living in constant fear

(b)Threat to the child/children’s safety

(c) Any other, specify

(a) Children might be kidnapped

(b) Any other, specify

12. Actually causing harm to the aggrieved

person/children/relatives

(a) Living in constant fear of further harm

(b) Any other, specify

(a) Repetition

(b) Escalation

(c) Fear of injury

(d) Any other, specify

13. Substance abuse

(drugs/alcohol)

(a) Living in constant fear of abusive and violent behaviour by the Respondent due to substance abuse

(b) Deprived of leading a normal life

(c) Any other, specify

(a) Physical violence after consuming the same

(b) Abusive behaviour after consuming the same

(c) Non-payment of maintenance / household expenses

(d) Any other, specify

14. History of criminal behaviour (a) Constant fear of violence

(b) Fear of revenge by the Respondent

(a) Respondent has a tendency to violate law and is likely to flout orders passed by the Court against him

(b) Respondent might cause harm to the aggrieved person/children for filing any further proceedings

(c) Any other, specify

15. Not provided money towards maintenance, food, clothes, medicines, etc. (a) Driven towards vagrancy and destitution

(b) Any other, specify

(a) Have to face great hardship to fulfill the needs and requirements of her child/children and herself

(b) Any other, specify

16. Stopped, disturbed from carrying on employment or not allowed to take up

the same

(a) Not able to fulfill the basic needs for yourself and your children

(b) Any other, specify

(a) Have to face great hardship to fulfill the needs and requirements of her child/children and herself

(b) Any other, specify

17. Forced out of the house, stopped from accessing or using any part of the house or prevented from leaving the same (a) Having no place to stay for yourself and your children

(b) Being restricted to a particular area of the house

(a) Safety of her child/children and herself

(b) Have to face great hardship in providing shelter for her and her children

(c) Any other, specify

18. Not allowed use of clothes, articles or things of general household use (a) Losing possession of the same

(b) Not having resources to replace the same

(a) The same may be disposed off by the Respondent

(b) Any other

19. Non-payment of rent in case of a rented

accommodation

(a) Being asked to leave the same by the owner on such non-payment

(b) No alternate accommodation to go to

(c) No income to afford a rented accommodation

(a) Losing shelter

(b) Facing great hardship

(c) Any other, specify

20. Sold, pawned stridhan or any other valuables without informing or without consent (a) Loss of valuables or property

(b) Any other, specify

(a) The same maybe disposed off by the Respondent

(b) Any other, specify

21. Dispossessed of stridhan (a) Deprived of the property in her

possession

(b) Any other, specify

(a) The same may be disposed off by the Respondent

(b) Fear of never receiving the same again

(c) Any other, specify

22. Breach of civil/criminal Court order, specify order Please specify Please specify
……………………………..

Signature

Aggrieved Person

……………………………..

Signature

Service Provider/Protection Officer/Police Officer

FORM VI

[See rule 11(1)]

Form For Registration As Service Providers Under Section 10(1) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

1. Name of the applicant
2. Address alongwith phone number, e-mail address, if any
3. Services being rendered ❑ Shelter

❑ Psychiatric counselling

❑ Family counselling

❑ Vocational Training Centre

❑ Medical Assistance

❑ Awareness Programme

❑ Counselling for a group of people who are victims of domestic violence and family disputes

❑ Any other, specify

4. Number of persons employed for providing such services
5. Whether providing the required services in your institution requires certain statutory minimum professional qualification? If yes, please specify and give details
6. Whether list of names of the persons and the capacity in which they are working and their professional qualification is attached? ❑ Yes

❑ No

7. Period for which the services are being rendered ❑ 3 years

❑ 4 years

❑ 5 years

❑ 6 years

❑ More than 6 years

8. Whether registered under any law/regulation ❑ Yes

❑ No

If yes, give the registration Number
9. Whether requirements prescribed by any regulatory body or law fulfilled?
If yes, the name and address of the regulatory body
Note.-In case of a shelter home, details under columns 10 to 18 are to be entered by registering authority after inspection of the shelter home.
10. Whether there is adequate space in the shelter home ❑ Yes

❑ No

11. Measured area of the entire premise
12. Number of rooms
13. Area of the rooms
14. Details of security arrangements available
15. Whether a record available for maintaining a functional telephone connection for the use of inmates for the last 3 years
16. Distance of the nearest dispensary/clinic/medical facility
17. Whether any arrangement for regular visits by a medical professional has been made? ❑ Yes

❑ No

If yes, name of the
Medical Professional
Address ……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
Contract number ……………………………………………………………………………………

……………………………………………………………………………………

Qualification ……………………………………………………………………………………

……………………………………………………………………………………

Specialisation ……………………………………………………………………………………

……………………………………………………………………………………

18. Any other facilities available, specify

……………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………….

Note.-In case of a counselling centre, details under columns 19 to 25 are to be entered after inspection by registering authority.
19. Number of Counsellors in the centre

……………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………….

20. Minimum qualification of the Counsellors, specify

❑ Under graduate

❑ Graduate

❑ Post graduate

❑ Diploma holder

❑ Professional degree

❑ Any other, specify

21. Experience of the Counsellors

❑ Less than a year

❑ 1 year

❑ 2 years

❑ 3 years

❑ More than 3 years

22. Professional qualification/experience of Counsellors

❑ Professional degree

❑ Experience in family counselling as a ………………………………………..(designation) in the ………………………………………..(Name of the organisation)

❑ Experience in psychiatric counselling as …………………………………….(designation) in the ………………………………………..(Name of the organisation)

❑ Any other relevant experience, please specify

……………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………….

23. Whether a list of names of Counsellors alongwith their qualifications has been annexed

❑ Yes

❑ No

24.(a) Type of counselling provided

❑ Supportive one-to-one counselling

❑ Cognitive behaviourable therapy (CBT) (Mental process that people use to remember, reason, understand, solve problems and judge things)

❑ Providing counselling to a group of people suffering

❑ Family counselling

(b) Facilities provided

❑ Offering personal professional and confidential counselling sessions

❑ A safe environment to discuss problems and express emotions

❑ Information on counselling services, support groups and mental health care resources

❑ One-to-one counselling and group work

❑ Therapies, ongoing counselling and health related support

❑ Any other, please specify

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

(c)

.

Any other service

(1) Services being provided

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

(2) Personnel appointed

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

(3) Statutory minimum qualifications required for providing such service

……………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

(4) Whether a list of names of personnel engaged for providing service alongwith their professional qualification is annexed

❑ Yes

❑ No

(5) Any other details which the service provider desirous of registration may provide

……………………….If necessary continue on a separate sheet.

Place ………………………………

Date ………………………………..

………………………………..

Signature of authorised official

Designation

FORM VII

[See rule 11(1)]

Notice For Appearance Under Section 13(1) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)

In The Court Of ……………………………………………………………..

P/S :………………………………………

In the matter Of:

Ms …………………………………………& Others ………………….COMPLAINANT
Versus
Mr …………………………………………& Others ……………………..RESPONDENT

To,

Mr ………………………………………………

S/o …………………………………………….

R/o …………………………………………….

…………………………………………………….

…………………………………………………….

Whereas the petitioner has filed an application(s) under section ………………..of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005).

You are hereby directed to appear before this Court on the ………………………..day of ………………………..20…………at…………O’clock in the………………………..noon personally or through a duly authorised counsel of this Court to show cause why the relief(s) claimed by the Applicant against you should not be granted, failing which the Court shall proceed ex parte against you.

Given under my hand and the seal of the Court of ………………………..on the……………………….. day of ………………………..20…………

……………………….

Signature

Seal of the Court

 

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