Sl.

No.

Date,

place and time of violence

Person

who caused domestic violence

Types

of violence

Remarks

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)