FORMS

INDEX
S. No. Form Corresponding Erstwhile Page Nos.
Section(s)
1. Notice for appearance by the S. 41-A, CrPC 2-3
police
[Sec. 35(3), BNSS]
2. Arrest Memo S. 41, CrPC 4-5
[Sec. 35, BNSS]
3. Bail Bond/Personal Bond S. 81, CrPC 6
[Sec. 83, BNSS]
4. Summons to produce S. 91, CrPC 7
document or thing
[Sec. 94, BNSS]
5. Form No. 13: bond to keep S. 106/107, CrPC 8
the peace
[Sec. 1251126, BNSS]
6. Summoning of Witness S. 160, CrPC 9
[Sec. 179, BNSS]
7. Form No.30: Bond to S. 170, CrPC 10
prosecute or give evidence
[Sec. 190, BNSS]
8. Form No. 47: Bond and bail- S. 436 I 436A I 437 I 437A I 11
bond for attendance before 438 I 441 , CrPC
officer in charge of police
station or court [Sec.
478/479148014811482(3)/
485, BNS S]
.
9. Seizure memo of documents 12
10. Request for Medical 13
Examination
11. Certificate [Sec. 63 (4)(C), S. 65-B, Indian Evidence Act 14-17
BSA]
12. Personal Search Memo S. 51, CrPC 18-19
[Sec. 49, BNSS]
13. Forwarding Letter (FSL) 20-22
14. Notice for Power to S. 175, CrPC 23
Summons person
[Sec. 195 BNSS]
15. Progress of Investigation - 24
[Sec. 193(3}(ii) BNSS]
16. Forms related to Juvenile Juvenile Justice Act 25-40
apprehension.

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 NOTICE FOR APPEARANCE BY THE POLICE
[as per section 35(3) of B.N.S.S.]

Case FIR No._______ U/s_____________________ Dated__________

PS________________
Diary No._______________ P.S._______________ Dated__________

To,
……………………………………………
[Name of the Accused/Noticee]
……………………………………………
[Last known Address]
……………………………………………
[Phone No./Email ID (if any)]

In pursuance of sub-section (3) of section 35 of the Bharatiya Nagarik

Suraksha Sanhita, 2023, I hereby inform you that during the investigation of
FIR/Case No ………………………… dated ………………… u/s
…………………………………………… registered at Police Station
………………………………………, it is revealed that there are reasonable grounds to
question you to ascertain facts 'and circumstances from you, in relation to the
present investigation. Hence you are directed to appear before me at
………………………… AM/PM on ………………………… at Police Station.

Although you are not being placed under arrest at this stage in respect of the
aforesaid FIR, you are directed to comply with all of the following
conditions/directions:

(a) You will not commit any offence in the future;

(b) You will not tamper with the evidence(s) in the case in any
manner whatsoever;

(c) You will not make any threat, inducement, or promise to any
person acquainted with the facts of the case so as to dissuade
him/her from disclosing, such facts to the Court or to the Police
Officer;

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 (d) You will appear before Court as and when required/directed;

(e) You will join the investigation of the case as and when required
and will cooperate in the investigation;

(f) You will disclose all the facts truthfully without concealing any
part relevant for the purpose of investigation to reach the true
and accurate conclusion of the case;

(g) You will produce all relevant documents/material required for the
purpose of investigation;

(h) You will render your full cooperation/assistance in apprehension

of the accomplice;

(i) You will not allow in any manner destruction of any evidence
relevant for the purpose of investigation/trial of the case;

(j) Any other conditions which may be imposed by the investigating

officer/SHO as per the facts of the case.

Failure to attend/comply with the terms of this Notice can render you liable
for arrest under S. 35(6) of the Bharatiya Nagarik Suraksha Sanhita, 2023.

____________ Police Station

Name and Designation of officer in charge

______________________________

(Seal)

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Case F.I.R/D.D No. ___________ Dated ________________
U/S _______ _____________________________________
P.S. ____________________ Dist. ____________________

ARREST MEMO
(as per section 35 of the Bharatiya Nagarik Suraksha Sanhita, 2023)

As per direction of Hon'ble Supreme Court of India.

1. Name with Alias and Parentage

of the Arrestee.
2. Mobile No/WhatsApp Mobile
No/Email Address.
3. Present Address of the
Arrestee.
4. Permanent Address of the
Arrestee.
5. FIR No./D.D. No. & Sec. of Law.
6. Place of Arrest.
7. Date & Time of Arrest.
8. Name, Address, e-mail ID &
Tel. No. Whomsoever to
convey the Arrest information.
9. Name, Rank & No. of Officer
who making arrest.
10.Reasons/Grounds of arrest.
a. Prevent Accused person
from committing any
further offence.
b. For proper investigation of
the offence.
c. To prevent the Accused
person from causing the
evidence of the offence to
disappear or tampering
with such evidence in any
matter.
d. To prevent such person
from making any

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 inducement threat or
promise to any person
acquainted the facts of the
case so as to dissuade him
from disclosing such facts
to the court or to the Police
officer.
e. As unless such person Address of the accused yet to be
arrested, his presence in verified.
the court whenever
required cannot be
ensured.

Signature of Arrestee
Witnesses:

1. _______________________________ Signature of the I.O

2. _______________________________ P.S. ________________

3. _______________________________ Dated ______________

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Case FIR No. __________ U/s ____________________ Dated ___________
PS ________________
BAIL BOND

I, ..........................................................., (Mobile No. / WhatsApp Mobile

No. ........................... Email. ............................................................... S/o
.................................................................... R/o
.......................................................... ……...............................................................
Hereby declare myself surety for Sh/Smt ...................................................., S/o
W/o D/o Sh...................................................................... Rio
................................................................... that he shall attend before
.......................................................................................... on the
..................................... Day of .......................................... to answer to the
charge on which he has been arrested and shall continue so to attend until
otherwise directed by the Court/Police and in case of this making default
therein, I bind myself to forfeit it to Government, the sum of
Rs..............................................................

(Signature)

Attested
PERSONAL BOND

l,............................................................ (name)(Mobile No. I WhatsApp Mobile

No................... Email ......................................................
S/o............................................................................
Rio..........................................................................................................................
....................
hereby bind myself to attend in the ……………....................................... on the
..................................... Day of .......................................... to answer to the said
charge and to continue so to attend until otherwise directed by the Court and
in case of making default therein, I bind myself to forfeit, to Government, the
sum of Rs...................................................

(Signature)

Attested

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Case FIR No. __________ U/s ____________________ Dated ___________
PS ________________

GD Entry No. ___________ DT. _____________ PS. _____________, MIZORAM

NOTICE U/s 94 B.N.S.S.

To,
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..

Sir,

This is to inform you that the above-mentioned case was registered on

the complaint of ........................................................................
S/o………………………………………………………...... R/o
.................................................................................................. The investigation
of the case is being carried by the undersigned.

For the purpose of investigation, you are hereby directed through this
notice to provide, or cause to be provided, the below mentioned
details/documents to the undersigned at PS...................................
on............................... at .................... A.M./P.M.: -

Kindly note that the failure to comply with the terms of this notice under
Section 94 of BNSS, as required may attract penal proceeding U/s 210 B.N.S.

1. ………………………………………………………………………………………………
2. ………………………………………………………………………………………………
3. ………………………………………………………………………………………………

Officer in charge, PS ………………….

PS …………………………………………….
Place ……………………………………….
Dt. ………………………….

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 FORM No. 13

BOND TO KEEP THE PEACE

(As per sections 125 and 126 of B.N.S.S)

WHEREAS I, ...................................................................................... (name)

(Mobile No./WhatsApp Mobile No ………………………………… email I.D.
..................................... inhabitant
of............................................................................................................(place),
have been called upon to enter into a bond to keep the peace for the term
of.............................................. or until the completion of the inquiry in the
matter of..............................................now pending in the Court
of.............................................., I hereby bind myself not to commit a breach of
the peace, or do any act that is likely to cause a breach of the peace, during the
said term or until the completion of the said inquiry and, in case of my making
default therein, I hereby bind myself to forfeit, to Government, the sum of
rupees.............................................

Dated, this …………………………………………. day of………………………………., 20 ……….

(Signature)

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Case FIR No. __________ U/s ____________________ Dated ___________
PS ________________
GD Entry No. ___________ DT. _____________ PS. _____________, MIZORAM

NOTICE U/s 179 B.N.S.S.

To,
…………………………………………………………………………..
…………………………………………………………………………..

Sir,

This is to inform you that the above-mentioned case was registered on

the complaint of ..................................................... S/o
................................................................................... R/o ....................
...............................................................................................................................
........................................................The investigation of the case is being carried
by the undersigned.

Whereas it appears that you are acquainted with the

facts/circumstances of the above cited case and investigation thereof. Hence,
you are hereby informed to appear before the undersigned on
................................ (date) at. ................................ (time) Police Station
........................................, Place ……………………….. in connection with above
cited case.

Name of I.O. ...................................

PS ...................................................
Place ..............................................
Dt..................................

Note: -
1. Failure to attend as required may attract penal proceeding U/s 208 B.N.S.
2. Person below 15 years’ age and above 60 years, woman or mentally or
physically disabled person or person with acute illness are exempted from
physical presence in police station unless they are themselves willing to
attend and join the investigation, as directed.

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Case FIR No.____________ U/S ____________________Dated __________
PS ________________________
GD No. _____________ P.S.___________ Dated _________

FORM No. 30
BOND TO PROSECUTE OR GIVE EVIDENCE
(As per section 190 of B.N.S.S.)

l, .........................................................(name) (Mobile No. / WhatsApp

...................................... Email. ............................................. of
............................................. (place), do hereby bind myself to attend
at ................................................. in the Court of
…………………......................................... at.............................................. o'clock
..............on the .............................................. day of....................... ...................
next and then and there to prosecute (or to prosecute and give evidence) (or
to give evidence) in the matter of a charge of..............................................
against one A. B., and, in case of making default herein, I bind myself to forfeit
to Government the sum of rupees............................

Dated, this ............................ day of .............................................., 20 .............

(Signature)

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 FORM No. 47
BOND AND BAIL-BOND FOR ATTENDANCE BEFORE OFFICER IN CHARGE OF
POLICE STATION OR COURT
[As per sections 478, 479, 480, 481, 482(3) and 485]

I, ..............................................(name), of..............................................(place),
having been arrested or detained without warrant by the Officer in charge
of..................................... .........police station (or having been brought before
the Court of..............................................), charged with the offence
of..............................................; and am required to give security for my
attendance before such Officer of Court on condition that I shall attend such
Officer or Court on every day on which any investigation or trial is held with
regard to such charge, and in case of my making default herein, I bind myself
to forfeit to Government the sum of rupees............................. Dated, this
.............................................. day of .............................................., 20 .............

(Signature)

I hereby declare myself (or we jointly and severally declare ourselves and each
of us) surety (or sureties) for the above
said..............................................(name) that he shall attend the Officer in
charge of..............................................police station or the Court
of..............................................on every day on which any investigation into the
charge is made or any trial on such charge is held, that he shall be, and appear,
before such Officer or Court for the purpose of such investigation or to answer
the charge against him (as the case may be), and, in case of his making default
herein, I hereby bind myself (or we, hereby bind ourselves) to forfeit to
Government the sum of rupees............................... Dated,
this.............................................. day of .............................................., 20
.............

(Signature)
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 Case FIR No.____________ U/S ____________________Dated __________
PS ________________________
GD No. _____________ P.S.___________ Dated _________

SEIZURE MEMO OF DOCUMENTS

In presence of the following witnesses,

........................................................................
S/o ........................................................, aged- ................... yrs. Mobile
No./ email ID ..............................................................
r/o..........................................................................., has joined the investigation
of the case at ............................................ and produced the below mentioned
documents: -
Sl No Description of documents/ articles PPs/Nos. Page Nos.
1.
2.
3.
4.

The above said documents are taken into police possession and seized as
evidence.
The seizure memo is prepared as per law.

Produced by

(..................................)
Witnesses: -
1) ……………………………………………….
2) ……………………………………………….

Name of I.O. .....................

PS......................................
Place ……………………………..
Dt ………………………………….
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Case FIR No.____________ U/S ____________________Dated __________
PS ________________________
GD No. _____________ P.S.___________ Dated _________

To,
The Chief Medical Officer,
……………………………..……....,
…………………Place …………....,
Sir,

With due respect I am sending

Mr./Mrs..................................................................................... S/o, D/o, W/o,
Sh.......................................R/o...........................................................................
Age ........................................... in the custody/protection of:

1. Const. .........................
No................................

2. W/Ct. ...........................
No.................................

It is, therefore, requested that the patient/Victim/injured may kindly be

medically examined and necessary exhibits, if any may please be preserved
and provided for the purpose of investigation into the case.

Thanking you,

Name of I.O....................
PS ……………………………….
Place …………………………..
Dt ……………………………….

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 CERTIFICATE U/s 63 (4)(C) OF B.S.A.
PART A
(To be filled by the Party)

I, …………………………………… (Name), Son/daughter/wife of

..………………………………… Residing/employed at ……………………………………………. do
hereby solemnly affirm and sincerely state and submit as follows: -
I have produced electronic record/output of the digital record taken
from the following device/digital record source (tick mark): -

Computer / Storage Media  DVR  CD/DVD  Mobile

Flash Drive 
Server  Cloud  Other 
Other: ………………………………
Make & Model: ……………………
Color: ………………………………
Serial Number: ………………………………
IMEl/UIN/UID/MAC/Cloud ID ……………………………… (as applicable) and any
other relevant information, if any, about the device/digital record
……………………………… (specify). The digital device or the digital record source
was under my lawful control for regularly creating, storing or recessing
information for the purposes of carrying out regular activities and during this
period, the computer or the communication device was working properly and
the relevant information was regularly fed into the computer in the ordinary
course of business. If the computer/digital device at any point of time was
networking properly or out of operation, then it has not affected the

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electronic/digital record or its accuracy. The digital device or the source of the
digital record is: -
Owned  Maintained  Managed  Operated 
by me (select as applicable).
I state that the HASH value(s) of the electronic/digital record(s) is
…………………………………….., obtained through the following algorithm:-
 DSHA1:
 SHA256:
 MD5:
 Other …………………………………………… (Legally acceptable standard)
(Hash report to be enclosed with the certificate)

(Name and Signature)

Date (DD/MM/YYYY): ……………………………..

Time (IST): …………………………… hours (In 24 hours format)
Place: ……………………………..

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 PART B
(To be filled by Experts)

I, …………………………………….. (Name), Son/daughter/wife of

..………………………………… Residing/employed at ……………………………………………. do
hereby solemnly affirm and sincerely state and submit as follows: -
The produced electronic record/output of the digital record taken from
the following device/digital record source (tick mark): -
Computer / Storage Media  DVR  CD/DVD  Mobile
Flash Drive 
Server  Cloud  Other 
Other: ………………………………
Make & Model: ……………………
Color: ………………………………
Serial Number: ………………………………
IMEl/UIN/UID/MAC/Cloud ID ……………………………… (as applicable) and any
other relevant information, if any, about the device/digital record
……………………………… (specify).
I state that the HASH value(s) of the electronic/digital record(s) is
…………………………………….., obtained through the following algorithm:-
 DSHA1:
 SHA256:
 MD5:
 Other …………………………………………… (Legally acceptable standard)
(Hash report to be enclosed with the certificate)

(Name and Signature)

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Date (DD/MM/YYYY): ……………………………..
Time (IST): …………………………… hours (In 24 hours format)
Place: ……………………………..

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Case FIR No. ………………… U/s …………………………………. Dated ……………….
PS………………………………..

Personal Search Memo

In the presence of the following witnesses, the personal search of Sh./Smt.....

.............................................. (Mobile No. I WhatsApp Mobile
No........................... Email ............................................ ..............S/o D/o W/o
(select as applicable) Sh............................
.................................R/o.................................................. .
............................................. was conducted as per law under the provisions of
section 49 of the Bharatiya Nagarik Suraksha Sanhita, 2023 and following
articles have been received from his/ her possession and same have been
taken into the Police possession through this memo.
1.
…………………………………………………………………………………………………………………………
……………………………..

2.
…………………………………………………………………………………………………………………………
……………………………..

3.
…………………………………………………………………………………………………………………………
……………………………..

Witness: -

(1) Sh................................................ (Mobile No……………..................... email ID

……......................)
........................................... S/o......................................
R/o........................................................

(2) Sh................................................ (Mobile No……………..................... email ID

……......................)

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........................................... S/o......................................
R/o........................................................

Investigation Officer ..............................

Police Station .........................................
Place ......................................................

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 FORWARDING LETTER

FIR No................................. Police Station:

……………........
Dated:................................. Distt:
....................................
State: ……………………….……….
Section of Law: ....................
NATURE OF CRIME:
(This should be cover with nature of charge, brief history and relevant details)

The brief facts of the case

.......................................................................................................................
...............................................................................................................................
..................................
...............................................................................................................................
...................................

LIST OF EXHIBITS SENT FOR EXAMINATION

S. 2 3 4 5
No.
1. Description of Source of the Marking No. of Sheets
Exhibits exhibits
1.
2.
3.

NATURE OF EXAMINATION REQUIRED: -

(Including any information which will assist the examination)

PLEASE OPINE: -

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1.
...............................................................................................................................
..............
2.
...............................................................................................................................
..............
3.
...............................................................................................................................
..............

Memo No. …………………… /SHO ..........................., ND Dated ………………….

/20 ...

Forwarded to the Director, Forensic Science Laboratory, Govt. of Mizoram,

Aizawl.

Dated: -

Specimen Seal Impression with sealing wax Signature and

designation
Officer of the forwarding
(With seal)

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 CERTIFICATE

1. Certificate to be signed by a competent forwarding authority and

forwarded to the Director, Forensic Science Laboratory, Govt. of Mizoram,
Aizawl.

2. Certified that Director Forensic Science Laboratory, Govt. of Mizoram,

Aizawl has authorized to examine the exhibits sent to him in connection with
the case FIR vide No. ............ dated ............, U/s................. P.S...............
..........or the purpose of examination.

Dated: - Signature and designation

Officer of the forwarding
(With seal)

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Case FIR No.____________ U/S ____________________Dated __________
PS ________________________
GD No. _____________ P.S.___________ Dated _________

NOTICE U/s 195 B.N.S.S.

To,
…………………………………………………………………,
…………………………………………………………………,
………………………………………………………………….

Sir,

This is to inform you that the inquest proceedings in respect of deceased

Late .......................................................................... S/o
…………………………………………....................................
R / o
...............................................................................................................................
h a v e b e e n
initiated to ascertain the cause of death. The enquiry into the matter is being
carried by the undersigned.

Whereas it appears that you are acquainted with the

facts/circumstances of the above cited matter. For the purpose of finalization
of the enquiry, you are hereby informed to appear before the undersigned on
date ................................ at................................ Police Station
..................................,
Place …………………………...

Name of I.O. ..................

PS...................................
Place …………………………..
Dt...................................

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Case FIR No.____________ U/S ____________________Dated __________
PS ________________________
GD No. _____________ P.S.___________ Dated _________

PROGRESS OF INVESTIGATION U/s 193(3){ii) BNSS

To,
Name ……………………………………………………………….
Address ……………………………………………………………
………………………………………………………………………….

Sir,

This is to inform you that the following progress in investigation has

been made in respect of the above-mentioned case which is/was being
investigated by the undersigned.

PROGRESS OF INVESTIGATION MADE SO FAR:

1.
...............................................................................................................................
......................
2.
...............................................................................................................................
......................
3.
...............................................................................................................................
......................

For further information or clarification in this regard, you may contact

your Investigating Officer or the inspector Investigation at P.S.
………………………………. on Saturday between 04 PM to 05 PM.

Name……………………..
Phone No. ……………..
Police Station/Unit……………..
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 Form (1)
[Rules 8 (1), 8 (5)]
SOCIAL BACKGROUND REPORT

FIR/DD No.: -
……………………………………………………………………………………………………..
U/Sections.: -
……………………………………………………………………………………………………..
Police Station: -
……………………………………………………………………………………………………..
Date & Time: -
……………………………………………………………………………………………………..
Name of I.O.: -
……………………………………………………………………………………………………..
Name of CWPO: -
……………………………………………………………………………………………………..
1. Name: -
……………………………………………………………………………………………………..
2. Father/Mother/ Guardian's name: -
......................................................................
3. Age/ Date of Birth: -
..............................................................................................
4. Address: -
……………………………………………………………………………………………………..
5. Religion: -
(i) Hindu (OC/ BC/ SC/ ST)
(ii) Muslim / Christian / Other (pl. specify)
6. Whether the child is different abled: -
(i) Hearing Impairment

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 (ii) Speech Impairment
(iii) Physically disabled
(iv) Mentally disabled
(v) Others (please specify)
7. Family Details: -
S. Name Ag Se Educati Occupati Inco Healt Histo Addictio
N and e x on on me h ry of ns
o. relations Statu ment
hip s al
illnes
s
1.
2.
3.
4.

8. Reasons for leaving Home: -

……………………………………………………………………………………….
9. Whether there is a history of involvement of family members in
offences, if any: - Yes/ No
10. Habits of the child: -
A B
Smoking Watching TV / Movies
Alcohol Consumption Playing indoor/ outdoor games
Drug use (specify) Reading books
Gambling Drawing / painting / acting / singing
Begging Any other
Any other

11. Employment details if any: -

.......................................................................
12. Details of income utilization: -
(i) Sent to family to meet family need YES/ NO
(ii) Used by self for: - YES/ NO
(a) For dress materials Yes/ No

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 (b) For gambling Yes/ No
(c) For alcohol Yes/ No
(d) For drug Yes/ No
(e) For smoking Yes/ No
(f) Saving Yes/ No
(g)
13. The details of education of the child: -
(i) Illiterate
(ii) Studied up to V standard
(iii) Studied above V standard but below VIII Standard
(iv) Studied above VIII Standard but below X Standard
(v) Studied above X Standard

14. The reason for leaving school: -

(i) Failure in the class last studied
(ii) Lack of interest in the school activities
(iii) Indifferent attitude of the teachers
(iv) Peer group influence
(v) To earn and support the family
(vi) Sudden demise of parents
(vii) Bullying in school
(viii) Rigid school atmosphere
(ix) Absenteeism followed by running away from school
(x) No age-appropriate school nearby
(xi) Abuse in school
(xii) Humiliation in School
(xiii) Corporal punishment
(xiv) Medium of instruction
(xv) Others (pl. specify)
15. The details of the school in which studied last: -
(i) Corporation I Municipal I Panchayat
(ii) Government I SC Welfare School/ BC Welfare School
(iii) Private management
(iv) School under NCLP
16. Vocational training, if any ....................................................................

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 17. Majority of the friends are
(i) Educated
(ii) Illiterate
(iii) The same age groups
(iv) Older in age
(v) Younger in age
(vi) Same sex
(vii) Opposite sex
(viii) Addicts
(ix) With criminal background

18. Whether the child has been subjected to any form of abuse:
Yes/ No
Sl. Type of abuse Remarks
No.
1. Verbal abuse -parents/ siblings/ employers/ others,
(pl. specify)
2. Physical abuse (pl. specify)
3. Sexual abuse parents/ siblings/ employers/ others,
(pl. specify)
4. Others (pl. specify)

19. Whether the child is a victim of any offence: - Yes/ No

20. Whether the child is used by any gangs or adults or Yes/ No
group of adults or has been used for drug peddling:
21. Reason for alleged offence such as parental neglect or
Over protection, peer group influence etc.
………………………………………………………………………………………………………………
………………………
………………………………………………………………………………………………………………
………………………
22. Circumstances in which the child was apprehended: -
………………………………………………………………………………………………………………
………………………

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 ………………………………………………………………………………………………………………
………………………
23. Details of articles recovered from the child: -
………………………………………………………………………………………………………………
………………………
………………………………………………………………………………………………………………
………………………
24. Alleged role of the child in the offence: -
………………………………………………………………………………………………………………
………………………
………………………………………………………………………………………………………………
………………………
25. Suggestions of Child Welfare Police Officer: -
………………………………………………………………………………………………………………
………………………
………………………………………………………………………………………………………………
………………………

……………………………
Signed by
Child Welfare Police Officer

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 FORM - XXV
APPREHENSION MEMO

FIR No. ………………………………., Dt. ………………………, U/s

…………………………………………………………….
P.S. ……………………………………., District ……………………………………., Place
…………………………………….

1. Name of the child with alias (if any) …………………………………….

2. Present address of the child - …………………………………….
3. Permanent address of the child- ...........................................
…………………………………….…………………………………….
4. FIR/DD No. & Section (s) of Law.............................................
5. Place of apprehension- ···························!································
6. Date & time of apprehension- ...................................................
7. Name, address & telephone number of the person informed: about
apprehension:
..........................................................................................................
8. Relation of the person with CCL- ………………………………………………….
9. Name, Rank and No. of the Officer- ……………………………………………..
Making the apprehension ………………………………...............................
10.Name, Rank and No. of the - ………………………………...............................
Child Welfare Police Officer-………………………………...............................

Witnesses with Address

1. ………………………………...............................
2. ………………………………...............................
3. ………………………………...............................

Signature by patent/guardian/
Probation Officer/ Social Welfare

Signature of Child Welfare Police Officer

P.S. ……………………… Place ……………….
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 FORM - XXVI
PERSONAL SEARCH MEMO

FIR No. ………………………………., Dt. ………………………, U/s

…………………………………………………………….
P.S. ……………………………………., District ……………………………………., Place
…………………………………….

In the presence of the following witnesses the personal search of CCL

……………………………………………. S/o ……………………………………………………….. R/o
……………………………………………………………………………. was conducted as per law
under provisions of Sec. 49 of B.N.S.S. the following articles have been
recorded from his/her possession.
1. …………………………………….…………………………………….
2. …………………………………….…………………………………….
3. …………………………………….…………………………………….

Witnesses: -

1. …………………………………….…………………………………….
2. …………………………………….…………………………………….
3. …………………………………….…………………………………….

CWPO .............................................
Signature of Child Welfare Police Officer
P.S. …………………... Place ……………………….

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 FINAL ORDER SLIP

FIR No. ………………………………., Dt. ………………………, U/s

…………………………………………………………….
P.S. ……………………………………., District ……………………………………., Place
…………………………………….

Name, Address & Description of Date of Offence Final Order

CCL apprehension U/s of Board

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……………………………………………………..
S/o ……………………………………………….
R/o ………………………………………………
……………………………………………………..
Age: - …….....

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 FORM – XXVII
UNDERTAKING

Undertaking to be given by parent/guardian/ fit person in whose custody

juvenile/child in conflict with law (JCL)/ Child in need of care and protection
(CNCP) is released by a police officer.
FIR/ DD Entry No. ……………………………………… Police Station
……………………………………………...................
Section of Law..............................................................
WHEREAS ................................ has been found to be in conflict with law/in
need of care and protection, and has been placed under the care and
supervision of (Name) ..........................................
............................................................................................................ (Address)
Subject to following condition, that: -
1. The child shall be produced before the Juvenile Justice Board (JJB) as and
when required by me.
2. The child shall remain under my supervision.
3. The Child shall reside at .........................................................................
and address of child shall not be changed without information to the
JWO/JJB/CWC.
4. The child shall be permitted to make endeavor to earn an honest
livelihood.
5. I shall arrange for the proper care, education and Welfare of the child.
6. The child shall not be allowed to associate with undesirable characters
and shall be prevented from coming in conflict with law again.
7. The child shall be prevented from taking Narcotic or Psychotropic
Substances or any other intoxicants.
This …………….. day of ……………….. 20........

Signature of parent / guardian / fit person

Counter signed by CWPO
P.S.: ………………………………………. Place …………………………….

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 ANNEXURE ‘I’
AGE-MEMO
(To be filled out in the case of youthful offenders)
As per the directions of Hon'ble High Court of Delhi in Writ Petition (Civil) No.-
8889 of 2011.

FIR No. …………………. Dated …………………… PS ……………………………….. Distt.

……………… Place ……………….

Name of the Arrestee

Name of Father & Mother Father
Mother
Date of Birth/Age as stated by the
arrestee
Permanent Address of the Arrestee
Name of available documentary
proof showing the age and date of
birth of the arrestee (if available)
Age as stated by the person who has
been informed of the arrest (to be
done only in case when arrestee does
not know his/her age)
Age as observed by the arresting
officer (to be entered only when the
age cannot be stated by the arrestee
and no one is available to give
information about the age)
Name of school and class last
attended and year of leaving
Has the arrestee been dealt with Yes Year
under the provision of the Juvenile No
Justice act, 2016 (Relevant column to Do not Probably yes
be ticked by the arrestee or his family remember
members/relatives)
History of prior inquiry in Juvenile Name of Juvenile Justice Board

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Justice Board (This column needs to FIR/DD No.:
be filled in as per the verification
done from the Nodal Special Juvenile Date of offence:
Police Unit Police Station:
U/s:
Whether copy of the age declaration
available with the arrestee or his
parents/relatives/next of kin:

Age as declared by the JJB:

District:

Age as the time of present offence as

per the age declaration done by the
JJB:
Witness: -
1.
Name & Number of JWO to whom
information of this arrest has been
given:
Date:
Time:

Name of the Investigating Officer or

any other police officers who
prepared this age memo: -
Rank & No.:

Police Station

District

Date & Time of Preparation of Age

memo:

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Signature of the police officer who
prepared this age-memo:

Receipt from Arrestee: -

I have received the copy of this age memo on date ………………… time
…………………. place.

(Name & Signature of arrestee)

Receipt from parents/Family: -

I have received the copy of this age memo on date ……………………. Time
…………………. place.

(Name & Signature of Father/Mother/Wife/Family member/Relatives of

arrestee)

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 INFORMATION OF APPREHENSION

FIR No./D.D. No. ………………………., Dt. ………………………, U/s

…………………………………………………………….
P.S. ……………………………………., District ……………………………………., Place
…………………………………….

To,

The Probation Officer,

…………………………………
………………………………..
………………………………..

Subject: Information regarding apprehension of JCL

.................................................................... S/o
..........................................................................................................
...................... DOB ..................................................... Mobile No
........................................................

Sir/Madam,

This is for your kind information please

I.O.: ………………………..
JWO: ……….……………..
PS: …………….……………

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 FORM - XXIV
REQUEST FOR MEDICAL EXAMINATION

FIR No./D.D. No. ………………………., Dt. ………………………, U/s

…………………………………………………………….
P.S. ……………………………………., District ……………………………………., Place
…………………………………….

To,
The Chief Medical Officer
………………………………………

Subject: Request for Medical Examination

Sir,
With due respect I am sending
Master/Ms........................................................................ S/o, D/o, W/o
Sh.......................................
.....................................................................................................
R/o.........................................................................................................................
...........................................................................................
.................................................. Age ............................................... in the
custody/protection of 1. Const...
..........................................................................No. ..................
2. W/Const. .......................................................................................................
No ................................
It is therefore, requested that the child/patient may kindly be medically
examined and opinion regarding his/her injuries/ailment may be furnished.

Thanking you,
Name of JWO .................................
P.S .................................... ....
Distt.....................................
Place ………………………………..
Date........................
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 VERSION OF CHILD IN CONFLICT WITH LAW

(To be recorded in presence of his father/mother/guardian/fit

person/probation officer)

…………………………………………………………………………………………………………………………
……………………………..
…………………………………………………………………………………………………………………………
……………………………..
…………………………………………………………………………………………………………………………
……………………………..
…………………………………………………………………………………………………………………………
……………………………..
…………………………………………………………………………………………………………………………
……………………………..
…………………………………………………………………………………………………………………………
……………………………..

Proceedings conducted
From ……………………………
To ………………………………..

Signature of father/mother/guardian/fit person/probation officer: -

Signature of I.O./CWPO

PS: ……………………………
Distt: ………………………..
Date: ……………………….
Follow up action recommended especially in case allegations of
mistreatment/abuser etc. are made out against any person on basis of version
of CCL.

Signature of I.O./CWPO

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