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This document appears to be a complaint form template for filing a complaint with the Lokayukta, which is an anti-corruption ombudsman in India. The form requests information such as the complainant's name and address, details of the public servant being complained about, facts of the complaint, nature of grievance, witnesses, supporting documents, and whether any previous complaints were filed. An affidavit from the complainant is also included.

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373 views4 pages

Forms

This document appears to be a complaint form template for filing a complaint with the Lokayukta, which is an anti-corruption ombudsman in India. The form requests information such as the complainant's name and address, details of the public servant being complained about, facts of the complaint, nature of grievance, witnesses, supporting documents, and whether any previous complaints were filed. An affidavit from the complainant is also included.

Uploaded by

nivyalawchambers
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

FORM NO.

I (COMPLAINT)
[See Rule 4(1)]

Before the Lokayukta/Upa-Lokayukta for Karnataka

Name and Address of the


Complainant for all
1
Correspondence in respect of
the complaint.
Name and Address of the
2 Public Servant complained
against:
Brief facts relating to the
action complained of:
3
(Complainant’s affidavit in
the Form-II to be enclosed)
If the complainant or the
person for whom he is acting
4 is aggrieved the nature of the
grievance should be
specifically mentioned:
If the complainant or the
person for whom he is acting
5 is aggrieved the nature of the
grievance should be
specifically mentioned:
Name and Address of the
witnesses whom the
6 complainant desires to
examine in support of the
allegations:
Particulars of the documents
relied upon by the
7
Complainant in support of the
allegation:
8 If the documents relied upon
or their true copies are
available with the
Complainant they should be
enclosed and details thereof
should be furnished.
If the documents relied upon -
are not in the custody of or
cannot be produced by the
9 Complainant, the office or
other places or individual
from whom they may be
secured should be specified.
Did complainant make a
complaint previously to
Lokayukta or the Upa-
Lokayukta or any other NO
authority for redressal of his
grievance. In respect of the
10
action now Complained of
against the public servant
mentioned in column (3).
(Particulars to be furnished
together with the result of
previous Complaint).
11 Remarks, if any.

Note:-
Copies of affidavits and documents shall be enclosed in duplicate for office use
and in as many sets as there are public servants complained against.
Place
Date
Signature or thumb impression
of the complainant
FORM NO. II (COMPLAINANT’S AFFIDAVIT)

See Rule 4(1)


BEFORE THE LOKAYUKTA/UPALOKAYUKTA OF
KARNATAKA

I, …………………………………. Son of Shri ………………………………….


Aged
…………………….. years, profession ………………………. Resident of
……………………………
Taluk, …………………………… District ……………………………. At
present at
………………………………… Taluk ……………………… District
…………………………… do
hereby solemnly affirm and state as follows:
1. That I am the Complainant in this case.
2. I have enclosed hereto a complaint making allegations against Sri/Smt.
……………………………………………………………………… The contents
of my complaint
may be read as part and parcel of this Affidavit.
3. That the statements of this complaint petition have been read by/read over to
me and understood by me and that I declare and affirm that they are true to the
best of my knowledge, information and belief.
Dated: Signature of the Deponent.
……………………………………………………………………………………
…
………………………………………… solemnly affirmed before me this
……………………
day of ……………………….200 …….. at ………………….
Signature

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