APPLICATION TO THE MAGISTRATE UNDER SECTION 12 OF THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 (43 OF 2005)
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To The Court of Judicial Magistrate .................................................. .................................................. ..................................................
Application under the Protection of Women from Domestic Violence Act, 2005 (43 of 2005). The applicant submits as under:
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)
2. 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 Courtdeems just and proper
(g) Pass any orders as deems” fit in the circumstances of the case.
3. 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 the applicant from going to applicant's place of employment [ ] Prohibiting Respondent(s) from entering the school/college/any other place of children of the applicant [ ]
Prohibiting from stopping the applicant from going to applicant's school [ ]
Prohibiting any form of communication by the Respondent with the applicant [ ] 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 out the applicant from the shared household [ ] Entering that portion of the shared household in which the applicant resides [ ] Alienating/disposing/encumbering the shared household [ ] Renouncing his rights in the shared household [ ]
An order entitling the applicant continued access to personal effects of the applicant [ ]
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-applicant [ ]
Any other person on her behalf, details of suchperson ...............................................
(vi) Compensation Order under section 22
(vii) Any other order, please specify ..................................................... ..
4. Details of previous litigation, if any (a) [ ]
Under the Indian Penal Code, sections ................... .
.Pending in the Court of ...................................................... .. [ ]
Disposed of, details of relief ......................................................... ..
(b) [ ]
Under Code of Criminal Procedure, sections ................... .. Pending in the Court of ................................................................... [ ]
Disposed of, details of relief ................................................ ..
(c) [ ]
Under the Hindu Marriage Act, 1956, .... .............. .. Pending in the Court of ................................................................. .. [ ] Disposed of, details of relief ......................................................... ..
(d) [ ] Under the Hindu Adoptions and Maintenance Act, 1956, sections ....... .._......Pending in the Court of [ ] Disposed of, details of relief ........................................................ ..
(e) [ ] Application for maintenance, under section ...... .. under ......... .. Act Interim maintenance Rs ............................... .. p.m. Maintenance granted Rs ............................... .. p.m.
(f) [ ] Whether Respondent was sent to Iudicial Custody A [ ]
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 / 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 — the applicant from domestic violence and in the interest of justice. Place .............. .. Date .............. ..
COMPLAINANT/AGGRTEVED 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
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