Case Number with State Code

Name and address of the complainant

Name of the victim

Date of incident

State and District relating to the incident

Nature of violation complained of

Classification of violation with Code No.

Disposed in limini

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Authority from whom the information report is called for

Disposed of

Without calling for compliance

with directions

After calling for compliance

Nature of directions / recommendation

Date of compliance

Date of Disposal

Date of destruction

Remarks

(9)

(10)

(11)

(12)

(13)

(14)

(15)

(16)