1.            Name Mention Complete Name.

2.            Sex Select Gender from list.

3.            Address Mention Complete address for


4. State Select name of your State from the list.

5. District Select name of your District from the list.

6. PIN PIN CODE of your locality, if available




7. Name Mention complete name of the victim

8. Address Mention Complete address of the victim

9. State Select name of State from the list, from

where the victim belongs to

10. District Select name of District from the list, from

where the victim belongs to

11. Sex Select Gender of the victim from the list,

If the number of victims are more than one

then Select ‘Group’ option.

12. No. of victims Mention number of victims.

13. Disability Select the disability status of the victim

from the list.

14. Age Mention age of the victim in years.

15. Religion Select Religion of the victim the list.

16. Caste Select Caste of the victim from list.




17. Place Mention exact place of incident i.e.


Village, Town, City

18. State Select Name of State from the list,

where incident occurred

19. District Select Name of District from the list,

where incident occurred

20. Incident Date Mention incident date (Date/Month/Year)

21. Incident Category Select incident category from the list

with whom the incident relates to

22. Incident Sub-Category Select incident sub- category from the

list which specifically shows the nature

of incident

23. Write complaint Brief summary of facts/allegations of the


24. Is it filed before any Court/State Select the option whether the complaint

Human Rights Commission of same incident is filed before any

Court OR State Human Rights




25. Name, designation & address of the Mention full details of Public Servant/

Public Servant Authority against whom the complaint is

being made.

26. Relief sought for Mention full details of relief, which is

sought against the human rights