Annexure-III
Model Form of Complaint
TITLE OF COMPLAINTS
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION AT………………..
Consumer Complaint No………………… of 19………………..
A. B. (add description and residence)……………………….. Complainant/Complainants

versus

C. D. (add description and residence)………………… Opposite Party/Opposite Parties

To
The Hon’ble President and his companion members of the State Commission.
Sirs,
The Complainant/Complainants named above respectfully submits/submit as follows:
1. All facts relating to the complaint, particulars, place, date etc. are to be stated.
2.
3.
4. Details regarding cause of action at the place where the complaint is being filed.
5. Details relating to jurisdiction and value of goods/services and compensation claim are to be given.
6. Prayer clause with details of relief/reliefs being claimed are to be stated.
Place………………..

Complainant/Complainants

Date………………..

In person or through Counsel

VERIFICATION

I/We……………….. (Complainant/Complainants) son/sons of……………….. resident of……………….. do hereby
solemnly declare and state that the contents/ particulars of the complaint stated above are true to the best of
knowledge and belief. Nothing stated therein is false and nothing has been mis-stated/concealed therein.
Verified at……………….. this…………….. day of……………….. 19………………..

Deponent

Annexures
1. ……………………
2. ……………………