Copies of the documents relied upon by the complainant and referred to in the complaint

An index of documents

Other documents as annexed along with the complaint

Signature of the complainant(s)

Verification

I __________ (name in full block letters) [son/ daughter] of ______ the complainant do hereby verify that the contents of paragraphs [1 to 9] are true to my personal knowledge and belief and that I have not suppressed any material fact(s).

Place:

Date:

Signature of the complainant(s)

Instructions: (1) Every complaint shall be filed in English and in case it is in some other Indian language, it shall be accompanied by a copy translated in English and shall be fairly and legibly type-written, lithographed or printed in double spacing on one side of standard petition paper with an inner margin of about four centimetres width on top and with a right margin on 2.5 cm, and left margin of 5 cm, duly paginated, indexed and stitched together in paper book form.

(2)

Every complaint shall be presented along with an empty file size envelope bearing full address of the respondent and where the number of respondents are more than one, then sufficient number of extra empty file size envelopes bearing full address of each respondent shall be furnished by the party preferring the complaint.

Form 'N'

[See rule 34(1)]

Complaint to Adjudicating Officer

Claim for interest and compensation under section 31 read with section 71

For use of Adjudicating Officers office:

Date of filing: ______________________

Date of [receipt at the filing counter/ receipt by post/ online filing]: ______________________

Complaint No.: ______________________

Signature: ________________________

Authorised Officer: ________________________

In the Adjudicating Officers Office (Name of place)

Between

______________________ Complainant(s)

And

______________________ Respondent(s)

Details of claim: