CIVIL

Format of complaint before the Lokpal of India

FORM OF COMPLAINT

[See rule 3]

Lokpal (Complaint) Rules, 2020.

PART A

DETAILS TO BE FURNISHED BY THE COMPLAINANT/SIGNATORY TO THE COMPLAINT

  1. Specify if the complaint is being made by

 

Individual                           Society                    Association of persons                 Trust                       Company    Limited Liability Partnership                                         Board                      Body                   Corporation         Authority            Others

 

2. Name of the complainant (in block letters)@

@ attach an identity proof.

 

NOTE: Any of the following documents will be considered as a valid proof of identity –

 

Driving License, Service Identity Cards with photograph issued to employees by Central/State Government/Public Sector Undertaking/Public Limited Company, Passbook with photograph issued by a Bank/Post Office, PAN Card, Smart Card issued by Registrar General of India under National Population Register, MNREGA Job Card, Health Insurance Smart Card issued under the scheme of Ministry of Labour, Pension document with photograph, Official identity cards issued to MPs/MLAs/MLCs, and Aadhaar Card.

 

 
  Title (Shri/Smt./Kum./Dr.etc.)    
  Surname    
  Middle Name    
First Name    
3. Gender Male Female Transgender  
       
4. Age

 

[in complete years]

 

   
5. Nationality$

 

$ in case the complainant is not a citizen of India, only a copy of the Passport will be accepted as a proof of identity

 

   
6.

Details of identity/residence proof to be enclosed with the complaint

 

 

Document attached (Tick the

appropriate box)

Driving Licence Passbooks with photograph issued by Bank/Post Office Smart Card issued by Registrar  General of India under the National Population Register MNREGA Job Card AadhaarCard  
         
   

 

 

PAN Card Service Identity Card with photograph

issued by Central/

State Govt./PSUs/ Public

Limited Companies to its employees

Health Insurance Smart Card issued under the scheme of Ministry of Labour Official identity cards issued to MPs/ MLAs/ MLCs, Pension document with photograph
             
  (a)    Number  
  (b)   Date of issue  
  (c)    Validity upto  
  (d)   Issuing Authority  
7. Permanent Address  
  House/Property Number/Locality  
  Village/District/City  
  State  
  Country  
  Pin Code/Postal or Zonal Code  
8. Address for correspondence

 

  House/Property

Number/Locality

 
  Village/District/City  
  State  
  Country  
  Pin Code/Postal or Zonal Code  
9. Occupation/

designation/

avocation:

 
10. (a) Telephone Number (with ISD/STD codes)   (b) Mobile Number (with country code)  
11. e-mail id  
12. Mode of presentation of the Complaint (Tick the appropriate column)

[see rule 4(1)]

(a) In-person  
(b) By Post
(c) Electronically

 

Note: A physical copy is to be provided to the Lokpal within a period of fifteen days.

13. Whether a duly notarized affidavit as annexed to this form has been enclosed? YES NO
   
14. Whether the complainant is the victim?

 

 

 

YES NO
   

 

It is certified that to the best of my knowledge, belief, and information:

(iii) The alleged offence in respect of which present complaint is being made is within the period of seven years [limitation as laid down under section 53 of the Lokpal and Lokayuktas Act, 2013];

 

(iv) no matter or proceeding related to allegation of corruption under the Prevention of Corruption Act, 1988 being made under this complaint is pending before any court or committee of either House of Parliament or before any other authority and the complaint is not barred from being made before the Lokpal by section 15 of the Lokpal and Lokayuktas Act, 2013.

 

 

Signature of the complainant/

authorised signatory

 

Place

Date

 

PART B

ADDITIONAL DEAILS TO BE FURNISHED BY THE SIGNATORY TO THE COMPLAINT IF THE COMPLAINT IS BEING FILED ON BEHALF OF A BODY OR BOARD OR CORPORATION OR AUTHOITY OR COMPANY, SOCIETY OR ASSOCIATION OF PERSONS OR TRUST OR LIMITED LIABILITY PARTNERSHIP

1. In case the complaint is made by a body or board or corporation or authority or company, society or association of persons or trust or limited liability partnership, then please indicate:
(a) Whether such organization as referred to above is based in India? (Tick the appropriate column) YES NO
   
(b) If the answer to (a) above is “YES” then whether the certificate of registration/incorporation  [as issued by the authority competent to issue such certificate in India or by authority competent to issue such certificate as per the regulating law of the Foreign State, as the case may be], in respect of such organisation has been enclosed? (Tick the appropriate column) YES NO
   
(c) Indicate the name of the competent authority which has issued the  certificate of registration/ incorporation of the organisation  
(d) Address for correspondence with the Organisation
  House/Property Number/Locality  
  Village/District/City  
  State  
  Country  
  Pin Code/Postal or Zonal Code  
(f) Telephone Number (with ISD/STD codes)   (b) Mobile Number (with country code)  
(g) e-mail id  
2. Personal details of office bearers and head of the organisation Furnish details in respect of each Office Bearer and Head of Organisation in the format as contained in Part A of this form.

[please see section 47 of the Act]

 

Attach separate sheets in respect of each individual.

3. Details of the person who hasauthorised the signatory to file the complaint on behalf of the organisation  
4. Name of the person authorising the signatory to file the complaint (in block letters)@

@attach an identity proof.

NOTE: Any of the following documents will be considered as a valid proof of identity-

Driving License, Service Identity Cards with photograph issued to employees by Central/State Government/Public Sector Undertaking/Public Limited Company, Passbooks with photograph issued by a Bank/Post Office, PAN Card, Smart Card issued by Registrar General of India under National Population Register, MNREGA Job Card, Health Insurance Smart Card issued under the scheme of Ministry of Labour, Pension document with photograph, Official identity cards issued to MPs/MLAs/MLCs, and Aadhaar Card.

 
  Title

(Shri/Smt./Kum./Dr.etc.)

   
  Surname    
  Middle Name    
  First Name    
5. Gender Male Female Transgender  
       
6. Age    
7. Nationality$

 

$ in case the person authorising the signatory is not a citizen of India, only a copy of the Passport will be accepted as a proof of identity

   
8. Details of identity/residence proof of the person authorising the signatory enclosed with the complaint  
  Document attached (Tick the appropriate box) Driving Licence Passbooks with photograph issued by Bank/Post Office PAN Card MNREGA Job Card Aadhaar Card  
           
    Smart Card issued by Registrar General of India under National Population Register Service Identity Card with photograph issued by Central/State Government / Public Sector Undertaking/ Public Limited Company to its employees Health Insurance Smart Card issued under the scheme of Ministry of Labour Official identity cards issued to MPs/ MLAs/ MLCs, Pension document with photograph  
       
  (a) Number    
  (b)Date of issue    
  (c)Validity upto    
  (d)Issuing Authority    
9. Permanent Address of person authorising the signatory  
  House/Property Number/Locality    
  Village/District/

City

   
  State    
  Country    
  Pin Code/Postal or Zonal Code    
10. Address for correspondence    
  House/Property Number/Locality    
  Village/District/City    
  State    
  Country    
  Pin Code/Postal or Zonal Code    
11. Occupation/

designation/

avocation:

   
12. (a) Telephone Number (with ISD/STD codes)   (b) Mobile Number (with country code)    
13. e-mail id    
14. Whether an authorisation document has been enclosed? (Please tick the appropriate box) YES NO  
     
15. Details of third party, if any, likely to be affected by the complaint      
(a) Name      
(b) Gender MALE FEMALE TRANSGENDER  
       
(c ) Age    
(d) Full Address    
(e) Telephone Number (with ISD/STD codes)   (b) Mobile Number

(with county code)

   
(f) e-mail Id    

 

PART C

DETAILS AS REGARDS THE PUBLIC SERVANT AGAINST WHOM THE COMPLAINT IS BEING MADE

1. Name of the public servant(s) against whom complaint is being made (in block letters)*

*attach a separate sheet in respect of each public servant against whom a complaint is being made.

Note: Details of third party/ parties, if aware, whose interests are likely to be prejudicially affected by the said complaint as contemplated under Section 21 of the Act may also be separately furnished

 
2. Present designation/status of the public servant(s) against whom complaint is being made  
3. Whether the complaint is against any officer or employee or agency (including the Delhi Special Police Establishment), under or associated with theLokpal? (tick the appropriate box)

[see section 38 of the Lokpal and Lokayuktas Act, 2013]

YES NO
   
4. With respect to serial no. 2 above, indicate: Designation of the officer/employee Organisation/Agency having administrative control over the said officer/employee
   

 

 

5(a). Category of the public servant against whom the complaint is being made (tick the appropriate box)

[see section 14 of the Lokpal and Lokayuktas Act, 2013]

The Prime Minister  
A Minister of the Union  
A Member of the Council of states (RajyaSabha)  
A Member of the House of the People (LokSabha)  
A Group ‘A’ or Group ‘B’ officer in the Ministry or Department of the Central Government  
    A Group ‘C’ or Group ‘D’ officer in the Ministry or Department of the Central Government  
    A Chairperson or a Member of a Body  
    A Chairperson or a Member of a Board  
    A Chairperson or a Member of a Corporation  
    A Chairperson or a Member of a Authority  
    A Chairperson or a Member of a Company  
    A Chairperson or a Member of a Society  
    A Chairperson or a Member of an Autonomous body  
    A Chairperson or a Member of a Trust  
    An officer or employee  of a Body  
    An officer or employee of a Board  
    An officer or employee of a Corporation  
    An officer or employee of anAuthority  
    An officer or employee of a Company  
    An officer or employee of a Society  
    An officer or employee of an Autonomous body  
    An officer or employee of a Trust  
    A Director, Manger, Secretary or other officer of association of persons, society or trust  
    Any other category  
5(b). In case the complaint is made against any other category of public servants, specify    
6. In case the complaint is against any Chairperson/Member/ Officer/Employee of a Trust or an Association of Persons or Society, indicate:

 

 
(a) Whether the organisation is wholly or partly financed by the Government (tick the appropriate box) YES NO
   
(b) Whether the annual income of the organisation exceeds one crore rupees as specified by the Central Government vide notification No. 407/02/2016-AVD-IV(Lokpal)(Pt.1) – [Notifications Numbers S.O.2154(E) and S.O. 2155(E)] dated 20th June, 2016 (tick the appropriate box)

 

[see clause (g) of sub-section (1) of section 14 of the Lokpal and Lokayuktas Act, 2013]

YES NO
   
(c ) Whether the Organisation is in receipt of any donation from any foreign source under the Foreign Contribution (Regulation) Act, 2010 in excess of ten lakh rupees in a year? (tick the appropriate box)

[see clause (h) of sub-section (1) of section 14 of the Lokpal and Lokayuktas Act, 2013]

YES NO
   
7. Please state, if aware, as to whether the public servant is presently serving the affairs of the State or in any body or Board or corporation or authority, etc. established by an Act of the State Legislature or wholly or partly financed by the State Government or controlled by it? (tick the appropriate box)

 

[see proviso under clause (f) of sub-section (1) of section 14 and proviso to sub-section (3) of section 14 of the Lokpal and Lokayuktas Act, 2013]

YES NO
   
8. Post held by the public servant at the time of commission of alleged offence under the Prevention of Corruption Act, 1988.

 

[see Explanation to section 14 of the Lokpal and Lokayuktas Act, 2013]

   
9. Details of the Cause of Action/offence (under the Prevention of Corruption Act, 1988).    
  (i)  Period during which alleged misconduct was committed.

[see Explanation to section 14 of the Lokpal and Lokayuktas Act,2013]

From to
   
  (ii) Place of occurrence:

 

 
  (iii)District:

 

 
  (iv)  State:  
10. Summary of facts/allegations of corruption: [Detailed complaint duly signed to be enclosed]

 

 

Facts and Circumstances:
  Details of the offences alleged under the Prevention of Corruption Act (Briefly indicate the facts and consequential allegations against the public servant which constitute offence(s) under the Prevention of Corruption Act, 1988)  
 

 

Allegations^:

 

^ if possible, indicate the statutory provision alleged to have been violated by a particular act of commission or omission

11. Names of Witnesses in support of the allegations, if any:    
  (a) Number of Witnesses:  
  (b) Name (s): 1. 2. 3. 4.
  (c) Gender:        
  (d) Age:        
  (e) Full Address:        
  (f) Mobile No.:        
  (g)E-mail Id:        
  Add additional sheets if the number of witnesses exceeds
12. Particulars/List of the documents relied upon by the Complainant in support of the allegation:  

 

 
13. Any other information, the complainant desires to furnish/disclose which may be relevant to inquiry/investigation into the allegation of corruption.    
14. Whether copies of the documents and other material evidence (including electronic evidence, if any) relied upon by the complainant and referred to in the complaint have been submitted?

(tick the appropriate box)

 

YES NO
   
   
   
15. If the complaint is being filed electronically whether pdf formats of the documents and other material relied upon has been attached to the electronic format of the complaint (tick the appropriate box)

 

[Please also see sub-rule (2) of rule 3 of these rules]

YES NO

 

 

                                                                                                                                 Signature of the complainant/ authorised person

 

  Place  
  Date ­­­­

day

 

month

 

year

 

PART D

AFFIDAVIT

 

(to be sworn on a non-judicial stamp paper)

 

I …………………………………………aged ………………………………..years, s/o ………………………………………………………….

r/o ………………………………………do here by solemnly affirm and declare on oath as under-

 

  1. That I am filing this complaint on my own behalf

OR

That I am filing this complaint on behalf of body/Board/  Corporation/ Authority/ Company/ society/trust/association of persons/Non-Governmental Organisation/ Limited Liability Partnership (give its name and registration number, if any) having their office at (give contact address/email/phone/fax of the organization) and that I am authorized to sign and make this complaint vide its resolution dated ……………..

 

  1. That I have filed the present complaint under the provisions of the Lokpal and Lokayuktas Act, 2013 and the rules made thereunder.

 

  1. That I have gone through the provisions of theLokpal and Lokayuktas Act, 2013 and do hereby affirm that the present complaint is in conformity therewith and I am fully aware that under the provisions of sections 46 and 47 of the Act making any false and frivolous or vexatious complaint is punishable with imprisonment for a term which may extend to one year and with fine which may extend to one lakh rupees.

 

  1. That neither I nor any other person in the organisation / institution / body that I represent in this complaint has filed any complaint in this matter before any Court or Committee of either House of Parliament or before any other Authority and this complaint does not attract the provisions of section 15 of the Act.

 

  1. I state that before filing this complaint I have collected and presented the information and supporting evidence to the best of my knowledge, ability and capacity which are relevant in support of the allegations of corruption against the concerned public servant and I further confirm that I have not concealed any data / material / information in this complaint.

 

Solemnly affirmed at ………………………. this …………………………..day of …………………………..20…………..

 

 

DEPONENT

Verification

I ………………………………….the above named deponent do hereby verify that the contents of the aforesaid paragraphs 1 to 5 are true and correct to the best of my knowledge and belief and nothing is concealed therefrom.

Verified at ……………………………this …………….day of ………………20………….

 

                                                                                                                                                                                                   DEPONENT

Disclaimer:

This document is based on the notified Form of Complaint as per Rule 3 of the Lokpal Act. This is an attempt to create a fill-able form for helping the complainants. The complainant is responsible for the accuracy of the Complaint form when he/she is sending the Complaint in the Form to the Lokpal. It must be noted by the complainants that the complaints not in the notified form are liable to be rejected by Lokpal.

Note: The Form as per the format should be emailed to [complaint-to-lokpal@gov.in] .

 

Categories: CIVIL

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