Report of incident of an act of violence and damage or loss of property

(See Section 6) 1. Details of the complainant or aggrieved person (a) Name of the complainant or aggrieved person: (b) Age: (c) Present Address: (d) Permanent Address: (e) Phone Number: 2. Details of person for whom complaint is made (in case where an aggrieved person is not in a position to make complaint) (a) Name of the complainant or aggrieved person: (b) Age: (c) Present Address: (d) Permanent Address: (e) Phone Number: 3. Details of incident (a) Date on which incident occurred: (b) Place of incident: (c) Name of persons involved in violence and damage or loss of property (d) Nature of violence: (e) Details of damage or loss to property (f) Approximate cost of damage or loss incurred to property 4. List of Document(s) attached 5. Assistance (a) Police assistance, if any, needed by the complainant or aggrieved person(s) (b) Assistance for initiating criminal proceedings and legal aid needed 6. Instructions for the police assisting in registration of a violence and damage or loss report Note: 1. Whenever information provided in this Form disclose an offence under the Indian Penal Code or any other Law, the police officer shall inform the aggrieved person that he can initiate criminal proceedings by lodging a First Information Report under the code of criminal procedure, 1973 2. In case of physical injury or pain reported by the aggrieved person, immediate medical assistance including medical examination shall be provided to the person. Place: Date: (Signature of competent authority) Name: Address: (Seal)