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(Under Section 154 Cr.P.C)

1.      District ___________ Police Station________ Year ________FIR No._____ Date_____

2.      Act___________ Sections______________


a.      Occurrence of offence: Date ________Time Period_____________

b.     Information received at Police Station Date_________ Time_________

c.      General Diary Reference: Entry No_________ Time____________

4.      Type of Information Written/Oral

5.      Place of Occurrence:

a.      Direction and distance from P.S__________ Beat No________

b.     Address________________

c.      In case,, outside the limit of this P.S., then Name of Police Station_____________________ District_______________________

6.      Complainant/Informant:

a.      Name_________________

b.     Father's/Husband's Name_________________

c.      Date/Year of Birth ___________

d.     Nationality

e.      Address_________________________

7.      Details of known/suspected/unknown accused with full particulars.

              i.         ____________________________________

             ii.         ____________________________________

8.      Reasons for delay in reporting by the complainant/informant

9.      Particulars of properties stolen____________________

10.   Total value of property stolen____________________

11.   Inquest Report/U.D case NO., if any__________________

12.   FIR Contents:_____________________

13.   Action Taken: Since the above information reveals commission of offence(s) u/s as mentioned at Item No.2:

1.      Registered the case and took up the investigation or

2.      Directed/Entrusted (Name of I.O)__________ Rank_________ No___________ to take up the Investigation or

3.      Refused investigation due to _____________ Or

4.      Transferred to P.S____________ District___________ on point of jurisdiction.

FIR read over to the complainant/informant, admitted to be correctly recorded and a copy given to the complainant/informant, free of cost.

Signature of Officer in charge, Police Station


Rank_________ No________

14.   Signature/Thumb impression of the complainant/informant.

15.   Date and time of dispatch to the court ___________________

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