DELHI STATE LEGAL SERVICES AUTHORITY

APPLICATION FORM FOR LEGAL AID

1. Name of Applicant:

2. Father’s/Husband’s Name:

3. Residential Address (Ph. No. if any):-

4. Category:
Schedule Caste S Schedule Tribe In Custody In Custody of a
Psychiatric hospital or
home
In custody of a protective Income < 1 Lac per Women or Girl Child Sr. Citizen Income
home annum < 4 Lac per annum

Child (Male/Female both) Transgender Income Disabled MACT Claimants

< 4 Lac per annum

Disaster Victims Missing Children Victim of Caste atrocity or Rape Victims

Industrial Workmen /Labour
Person infected and
affected with HIV Aids
any other atrocity
Delhi Victims Comp. Scheme Victim of Human Trafficking Acid Attack Victim
Beneficiaries or Begar

5. Whether Employed/Unemployed:

6. Place of Work:-

7. Nationality & Religion:

8. Whether SC/ST (Proof in support of it):

9. Income per month (Affidavit on Rs.10/- on non-judicial paper):-

9. Name and Address of opposite party & Tel. No. (If any):

10. Whether legal aid is required to file: Suit/Application U/s 125 Cr. P.C./Civil (Please state the
category) Writ/ Criminal Writ/ Labour Case/Service Matter/Criminal Matter/Other (pl. specify):-

11. Whether any application has been filed previously before this Authority, if yes, mention date and
file No. of application:-

12. Details of your problem (in brief) :

13. Please state whether any case is pending before, any court, if so, the details thereof:

14. Nature of relief sought: Want legal Aid legal Aid Advocate to

15. I undertake that if the legal services obtained by me on furnishing incorrect or false
information or in a fraudulent manner, the legal services shall be stopped forthwith and the
expenses incurred by the Legal Services Institutions shall be recovered from me.

SIGNATURE OF THE APPLICANT

 TO BE FILLED BY LEGAL AID COUNSEL

1.Summary of dispute:-

2.Recommendation of Legal Aid Counsel:-

Signature :

__________________
(Name in Capital letters)