Complaint Form

(To be filled in triplicate)

[Please see section 9 of the Act and the U.P. Lokayukta and Up-Lokayuktas (Complaints) Rules, 1977]

1. Name of the complainant

2. Father's or husband's name

(a) Occupation
(b) Whether you are public servant or not ?
(c) If the complaint is on behalf of any other person, state your relationship with that person (Also annex documents, any, to prove that you represent his estate or he bas authorized you in this behalf).

4. Permanent address
(a) Name
(b) Place
(c) Post Office or Police Station
(d) District

5. Address to which communication are to be sent
(a) Name
(b) Place
(c) Post Office or Police Station
(d) District

(1) Name designation (as at the time of the matter complained against) and present address (if known) of the person against whom complaint is being made.
(2) Date when the cause for the complaint arose.
(3) Reasons for delay in submitting the [being time barred under sub-section (4) of section 8].
(4) Whether any complaint was earlier made before a superior authority or proceedings taken before a Tribunal or a Court of law? If so, with what result? If not, please briefly state the reasons.

7. Whether it is
(a) an allegation* [as defined in section 2(b) of Act] or
(b) a grievance [as defined in section 2(d) of the Act]. 8. Challan no. and ate of deposit of security for cost under rule 4.

(1)The amount may be deposited in any branch of the State Bank of India under the Head "8443-Civil Deposits-00-103-Security Deposit-00-00"
(2) No amount is required to be deposited in the case of "grievance".
(3) A copy of the Challan should be attached to the complaint [see rule 8(2)].

9. List of persons who have sworn affidavits in support of the complaint.

*Section 2(b) "allegation" in relation to a public servant, means any affirmation that such public servant.
(i) has abused his position as such to obtain any gain or favour to himself or to any other person or to cause undue harm or hardship to any other person,
(ii) was actuated in the discharge of his functions as such public servant by personal interest or improper or corrupt motive, or
(iii) is guilty of corruption or lack of integrity in his capacity as such public servant.

Section 2(d) "grievance" means a claim by a person that he sustained injustice or undue hardship in consequence of maladministration.

10. Are there other persons who have knowledge about the facts relating to the complaint whom you would like to be summoned by the Lokayukta / Up-Lokayukta.

11. List of documents attached to the complaint including affidavit of the complainant.

12. The particulars of the complaint (here please state full fact of the complaint. Additional pages can be added, if the space below is insufficient).