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									                   WWW.PARIWARIKSURAKSHA.ORG

                                   MEMBERSHIP FORM

All information you provide is voluntary and will be kept confidential. You may use assumed
names. Information will be used to form part of a survey of victims of 498a.

 NAME

 ADDRESS



 PHONE NO.

 E-MAIL

 MARRIED --
 month/year

 HOW MARRIED                 ARRANGED
                             LOVE MARRIAGE
                             NEWSPAPER ADVT.
                             INTERNET SITE




 DISPUTE BEGAN --
 month/year

 AGE                         YOURS
                             SPOUSE’S
 YOUR JOB

 LIVING ARRANGEMENT          INDEPENDANTLY
                             JOINT FAMILY
 CHILDREN                    YES
                             NO
 PRIMARY REASONS
 FOR DISPUTE




 YOU ARE BEING               YES
 HARASSED,TORTURED
 AND THREATENED              NO
 WORKING ON MUTUAL           YES
 SETTLEMENT
                             NO
 COMPLAINT TO NGO’S          YES
                             NO
 COMPLAINT TO                YES
 POLICE STATION              NO
 COMPLAINT TO                YES
 WOMEN CELL                  NO
 FIR REGISTERED              YES
                             NO
COMPLAINTS, FIR          YOUR MATRIMONIAL
FILED AT                 RESIDENCE
(JURISDICTION) – CITY,   WHERE YOU GOT MARRIED
TOWN                     ANOTHER CITY


WERE YOU                 IF YES, HOW LONG?
ARRESTED ?               NO

YOUR BAIL STATUS         NOT APPLIED FOR
                         ARREST NOTICE
                         ANTICIPATORY BAIL
                         STAY /PROTECTION
                         INTERIM
                         REGULAR BAIL
BEFORE BAIL              HOW LONG?
GRANTED                  HOW MANY DATES?

CONDITIONS IMPOSED       PAY TO COMPLAINANT
AT THE TIME OF BAIL      DEPOSIT IN COURT
                         RETURN STRIDHAN
                         TRAVEL RESTRICTIONS
                         PASSPORT IMPOUNDED
                         PAY MAINTENANCE



HOW MANY FAMILY
MEMBERS WERE
ACCUSED ?
Details later

HAVE YOU RETURNED        NO      MUTUAL        RECOVERY     IN      IN
ANY STRIDHAN ? IF                AGREEMENT     BY POLICE    WOMEN   COURT
YES, HOW ?                                                  CELL
                         YES
YOU HAVE PROOFS OF       YES
YOUR INNOCENCE ?
                         NO


OTHER CASES FILED        RESTITUITION CONJUGAL
                         RIGHTS
                         JUDICIAL SEPERATION
                         DIVORCE
                         MAINTENANCE
                         CHILD CUSTODY




OTHERS ACCUSED
MOTHER’S NAME             POLICE COMPLAINT
INCLUDED IN               WOMEN CELL
                          FIR
                          CHARGE SHEET
                         HER BAIL STATUS
                         SHE WAS ARRESTED ? If yes, how    YES
                         long?                             NO
FATHER’S NAME             POLICE COMPLAINT
INCLUDED IN            WOMEN CELL
                       FIR
                       CHARGE SHEET
                      HIS BAIL STATUS
                      HE WAS ARRESTED ? If yes, how    YES
                      long?
                                                       NO
SISTER’S NAME          POLICE COMPLAINT
INCLUDED IN            WOMEN CELL
                       FIR
                       CHARGE SHEET
                      HER BAIL STATUS
                      SHE WAS ARRESTED ? If yes, how   YES
                      long?                            NO
BHABI’S NAME           POLICE COMPLAINT
INCLUDED IN            WOMEN CELL
                       FIR
                       CHARGE SHEET
                      HER BAIL STATUS
                      SHE WAS ARRESTED ? If yes, how   YES
                      long?                            NO
SISTERS HUSBAND’S      POLICE COMPLAINT
NAME INCLUDED IN       WOMEN CELL
                       FIR
                       CHARGE SHEET
                       BAIL STATUS
                       HE WAS ARRESTED ? If yes, how   YES
                      long?                            NO
BROTHERS NAME          POLICE COMPLAINT
INCLUDED IN            WOMEN CELL
                       FIR
                       CHARGE SHEET
                       BAIL STATUS
                       ARRESTED ? If yes, how long?    YES
                                                       NO
OTHERS                POLICE COMPLAINT
                      WOMEN CELL
                      FIR
                      CHARGE SHEET
                      BAIL STATUS
                      ARRESTED ? If yes, how long?     YES
                                                       NO



DO YOU WISH TO BE
CONTACTED ABOUT
OUR ACTIVITIES ?
DO YOU WISH TO
PARTICIPATE IN /
ORGANIZE LOCAL
VICTIM GROUPS ?

HOW WOULD YOU LIKE
TO HELP STOP MISUSE
OF 498A



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