FORMS

(See section 96) FORM 1 Application for Reception Order. (See sections 5.6) In the matter of A. B. (i), residing at ...................... by occupation ......................, son of .................. a person alleged to be a lunatic. To District Magistrate of or Sub-divisional Magistrate of , or Magistrate specially empowered under the Lunacy Act, 1977 ..................... The petition of C. D. (i), residing at ..., by occupation ............... ..., son of ........................ , in the .................. town of ............... (or sub-division of in the district of ..................). (1) I am (ii) years of age. (2) I desire to obtain an order for the reception of A. B. as a lunatic in the asylum of ..................... ..................... situate at (iii). (3) I last saw the said A. B. at ........................... on the (iv) day of ............. ;. ......... .................. (4) I am the ....:.... (v) of the A. B. (or if the petitioner is not a relative of the patient date as follows). I am not a relative of the said A. B. The reasons why this petition is not presented by a relative are as follows : (State them). The circumstances under which this petition is presented by me are as follows : (State them). (i) Full name, caste and titles. (ii) Enter the number of completed years. The petitioner must be at least eighteen or twenty– whichever is the age of majority under the law to which the petitioner is subject. (iii) Insert full description of the name and locality of the asylum or name, address and description of the person in charge of the asylum. (iv) A day within 14 days before the date of presentation of the petition is requisite. (v) Here state the relationship with the patient. (5) The persons signing the medical certificates which accompany the petition are (i). (6) A statement of particulars relating to the said A. B. accompanies this petition. (7) (If that be the fact). An application for an inquiry into the mental capacity of the said A. B. was made to the on the and a certified copy of the order made on the said petition is annexed thereto. (Or if that is the fact). No application for an inquiry into the mental capacity of the said A. B. has been made previous to this application. The petitioner therefore prays that a reception order may be made in accordance with the foregoing statement. (Sd) C. D. The statements contained or referred to in paragraphs are true to my knowledge ; the other statements are true to my information and belief. (Sd) C. D. Statement of particulars, (If any of the particulars in this statement be not known, the fact to be so stated). The following is a statement of particulars relating to the said A. B. Name of patient at length. Sex and age. Married, single or widow. Previous occupation. Caste and religious belief, as far as known. Residence at or immediately previous to the date hereof. Names of any near relatives to the patient who are alive. Whether this is first attack of lunacy. Age (if known) on first attack. When and where previously under care and treatment as a lunatic. Duration of existing attack. Whether the patient is known to be suffering from phthisis or any form of tubercular disease. Whether dangerous to others, and in what way. Whether any near relative (stating the relationship) has been afflicted with insanity. Whether the patient is addicted to alcohol, or the use of opium, ganja, charas, bhang, cocaine or other intoxicant. The statements contained or referred to in paras are true to my knowledge. The other statements are true to my information and belief. (Sd) Signature by person making the statement. (i) Here state whether either of the persons signing the medical certificates is a relative, partner or assistant of the lunatic or of the petitioner and, if a relative of either, the exact relationship. FORM 2 (See sections 7, 10) I, the undersigned E. F., being the District Magistrate of or the Sub-divisional Magistrate of or a Magistrate of the first class specially empowered by Government to perform the functions of a Magistrate under the Lunacy Act upon the petition of C. D. of (a) in the matter of A. B., (a) a lunatic, accompanied by the medical certificate of G. H., a medical officer, and of J. K., a medical practitioner (or medical officer), under the said Act, hereto annexed, hereby authorise you to receive the said A. B. into your asylum. And I declare that I have (or have not) personally seen the said A. B. before making this order. (Designation as above). FORM 3 (See sections 18, 19). In the matter of A. B. of (i) in the town of (or the subdivision of in the district of) an alleged lunatic. I, the undersigned C. D., do hereby certify as follows :- (1) I am a gazetted medical officer (or a medical practitioner declared by Government a holder of (ii) or declared by the Government to be a medical officer under the Lunacy Act and I am in the actual practice of the medical profession). (2) On the day of 19 at (iii) in the town of (or the village subdivision of in the district of) (separately from any other practitioner) (iv), I personally examined the said A. B. and came to the conclusion that the said A. B. is a lunatic and a proper person to be taken charge of and detained under care and treatment. (3) I formed this conclusion on the following grounds, viz— (a) Facts indicating insanity observed by myself, viz— (b) Other facts (if any) indicating insanity communicated to me by others, viz—Here state the information and from whom. (Sd) C. D. (Designation as above). (a) Address and description. (b) To be addressed to the officer or person in charge of the asylum. (i) Insert residence of patient. (ii) Insert qualification to practise medicine and surgery registerable in the United Kingdom (now India). (iii) Insert place of examination. (iv) Omit this when only one certificate is required. FORM 4 Omitted. FORM 5 Reception Order in case of wandering or dangerous lunatics or lunatics not under proper control or cruelly treated (sent to an asylum established by Government.) (See sections 14, 15) I, C. D., the District Magistrate of or the sub-divisional Magistrate of or a Magistrate specially empowered by Government under the Lunacy Act having caused A. B. to be examined by E. F., a Medical Officer under the Lunacy Act, and being satisfied that A. B. (describing him) is a lunatic who was wandering at large (or a person dangerous by reason of lunacy) (or is a lunatic not under proper care and control or is cruelly treated or neglected by the person having the care or charge of him) and a proper person to be taken charge of and detained under care and treatment, hereby direct you to receive the said A. B. into your asylum. (Sd) C. D. (Designation as above). Dated the To the officer incharge of the asylum at FORM 6 Case when sent to a licensed asylum. I, C. D., (as above down to "care and treatment") and being satisfied with the engagement entered into in writing by G. H. of (here insert address and description) who has desired that the said A. B. may be sent to the asylum at (here insert description and name of the person incharge) to pay the cost of maintenance of the said A. B. in the said asylum, hereby authorise you to receive the said A. B. into your asylum. (Sd) C. D. (Designation as above). Dated the To the person incharge of the asylum at FORM 7 Bond on the making over of a lunatic to the care of relative or friend. Whereas A. B., son of inhabitant of , has been brought up before C. D., District Magistrate of , or a Sub-Divisional Magistrate of the first class specially empowered under the Lunacy Act, and is a lunatic who is deemed to be dangerous (or deemed to be a lunatic who is not under proper care and control or is cruelly treated or neglected by the person having the charge of him) and whereas I, E. F., son of inhabitant of have applied to the Magistrate that the said A. B. may be delivered to my care; I, E. F., above named hereby bind myself that on the said A. B. being made over to my care, I will have the said A. B. properly taken care of and prevented from doing injury to himself or to others, and in case of my making default therein, I hereby bind myself to forfeit to the Government the sum of rupees Dated this day of 19 . (Sd) E. F. Dated : (Where a bond with sureties is to be executed add) We do hereby declare ourselves sureties for the above named E. F. that he will, on the aforesaid A. B. being made over to his care, have the said A. B. properly taken care of and prevented from doing injury to himself or to others ; and in the case of the said E. F. making default therein, we bind ourselves, jointly and severally, to forfeit to the Government, the sum of rupees Dated this day of 19 . FORM 8 Bond on the discharge of a lunatic from an asylum on the undertaking of relative or friend to take due care. (See section 33) Whereas A. B., son of , inhabitant of is a lunatic who is now detained in the asylum at under an order made by C. D., or the District Magistrate of , or a Sub-divisional Magistrate of the first class specially empowered under the Lunacy Act under section 14 (or section 15) of the Lunacy Act and whereas I, E. F., son of inhabitant of have applied to the said Magistrate that the said A. B. may be delivered to my care and custody ; I hereby bind myself that on the said A. B. being made over to my care and custody, I will have him properly taken care of and prevented from doing injury to himself or to others ; and in case of my making default therein I hereby bind myself to forfeit to the Government the sum of rupees Dated this day of 19 . (Sd) E. F. (Where a bond with sureties is to be executed) – We do hereby declare ourselves sureties for the above named E. F. that he will, on the aforesaid A. B. being delivered to his care and custody, have the said A. B., properly taken care of and prevented from doing injury to himself or to others ; and in case of the said E. F. making default therein, we bind ourselves, jointly and severally, to forfeit to the Government, the sum of rupees Dated this day of 19 .