Made under: DV Act s.12, 2005
Application for protection from domestic violence — s.12, Domestic Violence Act, 2005
Fill in the blanks
Everything you type here stays in your own browser. Nothing is sent anywhere, nothing is saved, and we never see it. Close the page and it is gone — so print before you close it.
Leave a field empty and a blank line is printed in its place, to be filled in by hand. Printing the empty form and carrying it with you is a perfectly good use of this page.
Exactly as it appears on your Aadhaar or ID.
E.g. wife, son, father — with the date of marriage or birth.
Write it in the order it happened. Do not guess at anything you cannot remember.
For example: a full refund, a replacement, compensation, the cost of the case — one demand per line, with the amount.
The document
In the Court of the Learned Judicial Magistrate First Class / Metropolitan Magistrate, ________________
Case No. ........ of ........
________________, resident of ________________ ...... Aggrieved person / Applicant
versus
________________, resident of ________________ ...... Respondent
APPLICATION UNDER SECTION 12 OF THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005
Made under: Section 12 of the Protection of Women from Domestic Violence Act, 2005; reliefs under Section 18 (protection order), 19 (residence order), 20 (monetary relief), 21 (custody order) and 22 (compensation).
The applicant respectfully submits:
1. The applicant's relationship with the respondent: ________________. They lived / live together in a shared household.
2. The acts of domestic violence (physical, sexual, verbal and emotional, economic — Section 3), with dates:
________________
3. A Domestic Incident Report has / has not been recorded with the Protection Officer (particulars: ........).
4. The reliefs sought:
________________
PRAYER: It is prayed that the above reliefs be granted, and that an immediate ex parte interim order be passed (Section 23).
Applicant
________________
Place: ________________
Date: ________________What to attach
- The Domestic Incident Report, if the Protection Officer made one.
- Proof of the marriage or relationship and of the shared household.
- Medical papers, photos, messages, police complaints — whatever exists.
- For monetary relief, the income and assets affidavit (Rajnesh v. Neha).
- Free help: the Protection Officer or the District Legal Services Authority.