FORM-I

[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
1. Details of the complainant/aggrieved person:
(1) Name of the complainant/aggrieved person:
(2) Age:
(3) Address of the shared household:
(4) Present Address:
(5) Phone Number, if any:
2. Details of Respondents:

Relationship with the Telephone No.

S.NO. NAME Address
aggrieved person if any

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

(a) Number of Children:
(b) Details of Children:

Name Age Sex With whom a present residing

4. Incidents of domestic violence:

Date, place and Person who caused Types of Violence

S.NO. Remarks
time of violence domestic violence Physical Violence
Causing hurt of any kind
(Please specify)

(i) Sexual Violence

Please tick mark [ √ ] the column applicable

 Forced sexual intercourse

 Forced to watch pornography or
other obscene material
 Forcibly using you to
entertain others
 Any other act of sexual
nature, abusing,
humiliating, 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 bringing
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.
 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)

(iv) Dowry related harassment

 Demands for dowry made,
please specify.
 Any other detail with regard to
dowry, please specify.
Whether details of dowry
items, stridhan, etc. attached
with the form.
 Yes
 No

(v) any other information regarding acts of domestic violence against you or your
children.
(Signature or thumb impression of the complainant/aggrieved person)

5. 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

6. Order that you need under the Protection of Women from Domestic Violence Act.
2005.
Sl. 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)

7. Assistance that you need

Sl. NO. Assistance available Yes/No Nature of Assistance

(1) (2) (3) (4)
1 Counsellor
2 Police assistance
3 Assistance for initiating criminal
proceedings
4 Shelter home
5 Medical facilities
6 Legal aid

8. Instructions 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—
(a) inform the aggrieved person that she can also initiate criminal proceedings by lodging
a First Information Report under the Code of Criminal Procedure, 1973.

(b) 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.

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

Place: (Counter Signature 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