FORM 1

 

[See Rule 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) [CD1] 

 

 

 

Details of the complainant /aggrieved person

 

Name of the complainant/aggrieved person:

Age :

Address of the shred household :

Present Address :

Phone Number, if any :

Details of Respondents :

 

Sl.

No.

Name

Relationship with the aggrieved person

Address

Telephon e No. if any

 

 

 

 

 

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

Number of Children:

Details of children :

 

Name

Age

Sex

With   whom    at

present residing

 

 

 

 

Incidents of domestic violence:

 

Sl.

No.

Date, place and time of

violence

 Person who  caused domestic violence

Types of violence

 

 

Physical violence

Remar

ks

Causing hurt of any kind, please specify.

II SEXUAL VIOLENCE

Please tick mark [  the column applicable

 

 

 

Forced          sexual

intercourse

Forced to watch pormo- graphy or other obscene

material

Forcibly using you to entertain others

Any other act of sexual nature, abusing humilia- ting, 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 brining 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

 

 

 

 

o Demands for dowry made, please specify:

o Any other detail with regard to dowry, please specify

Whether details of dowry items, stridhan, etc. attached with the form.

o Yes

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

  

 

 

 

 

 

DOWRY RELATED HARASSMENT

:

 

 

 

 

 

 

 

 

No

 

 

 

 

G.207 /07/DTP.

 

 

 

 

 

 

 

 

 

any other information regarding acts of domestic violence against you or your children.

 

 

 

 

 

 

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

 

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

 

 

Order that you need under the Protection of Women from Domestic Violence Act, 2005.

 

S.

No.

Orders

Yes/No

Any other

(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)

 

 

Assistance that you need

 

S. No.

 Assistance available

Yes/No

Nature assistance

of

(1)

(2)

(3)

(4)

 

(1)

Counsellor

 

 

 

(2)

Police assistance

 

 

 

(3)

Assistance for initiating criminal proceedings

 

 

 

(4)

Shelter home

 

 

 

(5)

Medical facilities

 

 

 

(6)

Legal aid

 

 

 

 

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— 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 1973) 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.

 

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

 

Place: (Countersignature       of      Protection   Officer/Service Provider) Date:         Name:

Address:

 

(Seal)

 

Copy forwarded to:—

1.   Local Police Station

2.   Service Provider/Protection Officer

3.   Aggrieved person

4.   Magistrate

 [CD1]DOMESTIC INCIDENT REPORT UNDER SECTIONS 9 (B) AND

37 (2) (C) OF THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 (43 OF 2005)