Form for submitting a Complaint * BEFORE THE LOK AYUKTA CONSTITUTED UNDER SECTION 4 OF THE KERALA LOK AYUKTAACT 1999 (ACT 8 OF 1999) COMPLAINT NO: ............................................................... OF 200.... - 200.... A.B. C.D. (Add name and address) And (Add name, official designation (if any) and address) : Between } } Complainant Respondent 1. Name of the Complainant : 2. Father's or Husband's name : 3. (a) Age : (b) Occupation : (c) Whether the complainant is a public servant or a service association : or a Trade Union 4. Permanent Address : (a) Name : (b) House Number : (c) Street/ Road : (d) Village/ Ward : (e) Post Office : (f) Taluk : (g) District : 2 5. Nature, description and particulars including the approximate date or period of the action alleged to have : been committed, in respect of allegations/ grievances are made in the complaint. 6. Name and address of other persons (if any) who have knowledge about the facts relating to the complaint : whom the complainant would like to be summoned by the Lok Ayukta/ Upa Lok Ayukta. 7. Documents attached to the complaint. Place : Date : Signature of the Complainant I / We declare that what is stated in paragraph ( ) is true to my/our knowledge and that what is stated in paragraph ( ) is based on the information which is believed to be true. Signature : Date : Note :-(The form can be copied out on plain paper by the complainant, Additional pages can be added according to the requirments of the nature and describption of the alleged corruption. Every complaint and the documents accompanying it shall be in quadruplicate, accompanied by as many number of spare copies as there are public men against whom allegations of corruption have been made in the complaint) 3 BEFORE THE LOK AYUKTA, THIRUVANANTHAPURAM Complainant : Respondents : AFFIDAVIT FILED BY THE COMPLAINANT I, ...................................................................................... S/o ..................................................................... aged, ................ residing at ............................................................................................................................................. .................................................................................................................do solemnly affirm and state as follows : 1. I am the Complainant in this case. This Complaint is filed against the respondents. 2. I know the facts of this case. The statement made in the accompanying complaint may be treated as part of this affidavit. 3. All the facts stated in the complaint are true. 4. The complaint is entitled to the reliefs prayed for in the complaint. All the reliefs prayed for in the complaint may be allowed. All the facts stated herein are true to the best of my knowledge, information and belief. Dated this on ...........th day of ............................200...... Deponent Solemnly affirmed and signed before me by the Deponent, who is personally known to me and he signed the same on ........................................................... at my office. Gazetted Officer/Advocate 4
