| State*: |
|
District*: |
|
| Application For *: |
|
| Applicant Name *: |
|
Gender *: |
|
| Name of Victim *: |
|
Gender *: |
|
| Father Name *: |
|
Occupation *: |
|
| Mother Name *: |
|
Occupation *: |
|
| Relation of applicant with victim *: |
|
| Age of Victim *: |
|
Date of Birth of Victim *: |
|
| Address of Applicant *: |
|
| State*: |
|
District:* |
|
| Mobile *: |
|
Email*: |
|
