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Form of Application-Cum-Affidavit Seeking Free Legal Services

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Chandrika Dani
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23 views

Form of Application-Cum-Affidavit Seeking Free Legal Services

Education purpose

Uploaded by

Chandrika Dani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM OF APPLICATION-CUM-AFFIDAVIT

SEEKING FREE LEGAL SERVICES

Application-cum-Affidavit Form for providing free legal services under Section 12


of Legal Services Authorities Act, 1987 read with Rule-16 of the Uttarakhand
State Legal Services Authority Rules, 2006.
To,
The Member Secretary,
Uttarakhand State Legal Services Authority,
High Court Campus,
Nainital.
OR
The Registrar General/Secretary,
High Court Legal Services Committee,
Nainital.
OR
The District Judge/Chairman,
District Legal Services Authority,
District Court Compound,
District………………………………
OR
The Chairman,
Tehsil Legal Services Committee.
Tehsil……………………….
District………………………

1. Particulars:-
(a) Name of applicant (with telephone number, if any)
..........................................................................................................................................

(b) Name of Father/Husband


.........................................................................................................................................

(c) Occupation
.........................................................................................................................................
(d) Full Correspondence Address
.........................................................................................................................................

(e) Detail of Annual Income (Attach Certificate/Affidavit)


........................................................................................................................................

(f) Whether the applicant is -(i) A member of a Scheduled Caste or Scheduled Tribe (attach
certificate);
Or

(ii) A victim of trafficking in human being or beggar as referred to in Article 23 of the


Constitution;
Or

(iii) A Woman;
Or

(iv) A Child;
Or

(v) A Mentally ill or otherwise disabled person;

Or
(vi) A person under circumstances of undeserved want such as being a victim of a mass
disaster, ethnic violence, caste atrocity, flood, drought, earthquake or industrial disaster;

Or
(vii) An Industrial workman;
Or
(viii) A person in custody, including custody in a protective home within the meaning of
clause (g) of section 2 of the Immoral Traffic (Prevention) Act, 1956 or in a juvenile home
within the meaning of clause (i) of section 2 of the Juvenile Justice Act, 1986; in psychiatric
hospital or psychiatric nursing home within the meaning of clause (g) of section 2 of the
Mental Health Act, 1987;
Or

(ix) In receipt of annual income from all sources less than rupees one lakh or such other
higher amount as may be prescribed by the State Government, if the case is before a court
other than the Supreme Court. (Attach Certificate/affidavit duly attested by
Notary/Magistrate).
Or
(x) Ex-Serviceman (attach certificate)

2. Mode in which Legal Aid is required:


Whether:
(a) Through Legal Advice,
Or
(b) By way of engaging counsel to prosecute or defend a case,
Or
(c) Legal service through Mediation Centre.

3. Name and Address of the opposite party, with telephone number (if any)

...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
4. Brief facts of the case
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

NOTE : - Attach separate sheet of plain paper (if required).

5. Any other matter which the applicant may wish to highlight.


6. Affidavit:

I solemnly affirm and declare that the above mentioned facts are true and correct according
to my own knowledge and belief and further that I have not concealed any fact therefrom.
I further solemnly affirm and declare that I have been made to understand that in case of
any false affirmation of facts, I shall be liable for legal action.
I shall comply with any requisition and direction that may be made by the Member
Secretary/Secretary/Chairman of the concerned Authority/Committees.
I further declare that no such or similar petition on the same cause of action has been filed
by me earlier in any other capacity in any Court of competent jurisdiction.

Place: ______________ Signature or thumb


impressions of the
deponent/applicant.
Dated:_____________

--------------------------------------------------------------------------------------------------------------------------

VERIFICATION

Verified that the contents of my above affidavit are correct and true to my own knowledge
and that nothing has been concealed therefrom.

Place: ______________ Signature or thumb


impressions of the
deponent/applicant.
Dated:_____________

Note:-
This affidavit must be sworn on non-judicial stamp paper of appropriate value under the
Stamp Act of our State and attested by Notary Public.

Seal of Notary Public


--------------------------------------------------------------------------------------------------------------------------

Note:-

(1) In the case of minors or persons of unsound mind, the application is to be made by
his/her next friend/guardian and his/her own affidavit is also to be sworn by the next
friend/guardian and got attested.

(2) Tick mark the relevant and strike off the irrelevant column.

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