SCLSC-4
Relevant to clause (2) of Regulation
17
AFFIDAVIT
1…………………………………………………………………. aged about…………………………..years son/ daughter of/ wife of
Shri………………………………………………………………… Resident of …………………………………………………………… …………………….. do
hereby solemnly affirm and state as under :
(a)
I
belong to a member of a Scheduled Castes/ Scheduled Tribes.
(b)
I
am a victim of trafficking in human beings or a beggar.
(c)
I
am eligible for legal services as I am a woman/ child.
(d)
I
am mentally ill or otherwise disabled person.
(e)
I am a person under circumstances of
underserved want being a victim of a mass disaster, ethnic violence caste
atrocity, flood, drought, earthquake or industrial disaster.
(f)
I
am an industrial workman.
(g)
I
am in custody.
(h)
My annual income from all sources is
below Rs. 1,25,000/
(Rupees one lakh twenty five thousand).
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(Delete whatever is not applicable)
1.
I
shall comply with any requisition and direction that may be made by the
Secretary or any of the members of the Supreme Court Legal Services Committee.
2.
I
shall furnish full and true information of all facts of my case to the legal
service advocate to be provided by, the committee.
3.
I
seek to approach the Hon' ble Supreme Court of India :(a) In appeal from the
Judgement of
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(b)
In
writ jurisdiction for .
(Delete whatever is not applicable)
4.
I
agree that my case be listed before Lok Adalat in Hon'ble Supreme Court, if any
stage it is considered by the Committee that my matter can be reconsidered or
settled through Lok Adalat.
DEPONENT
Verification
I, Shri/Smt./Kum.
the
above-named Deponent do hereby verify that the contents of the Paragraphs 1 to
5 are true and correct to my knowledge nothing stated therein false and nothing
has been concealed.
Verified on this day at . -------------------------------------------------------------
200 at
DEPONENT
Note : This affidavit must be on
non-judicial stamp paper of appropriate value under the Stamp Act of your State
and sworn before an Oath Commissioner or Notary Public or 1st Class Magistrate.