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In the matter of A, B.,1 residing at                     , by occupation                     , son

of                                       , a person alleged to he a lunatic,

To                                    Presidency Magistrate, for               [or                  District

Magistrate of                      , or Sub-Divisional Magistrate of

or                            Magistrate especially empowered under Act IV

of 1912                                                      for                               ].

The Petition of C. D.1 residing at                                , by occupation             s son

of                 , in the town of                                           [or Sub-Division of

in the district of                                                              ].

1.   I am                                    years of age.2

2.   I desire to obtain an order for the reception of A, B. as a lunatic in the asylum of

situate at3

3.   I last saw the said A, B. at                                 on the day4 of

4.   I am the •&                                          of the said A. B.

Or if the 'petitioner is not a relative of the patient state as follows:

I am not a relative of the said A. B.   The reasons why this petition is not presented
by a relative are as follows:   (State them).

The circumstances under which this petition is presented by me are as follows:
(State them.)

5.   The persons signing the medical certificates which accompany the petition are6

6.   A statement of particulars relating to the said A. B. accompanies this petition.

7.    (If that is the fact,)   An application for an inquiry into the mental capacity of
the said A. B. was made to the                      on the                      and a certified copy
of the order made on the same petition is annexed hereto.   (Or if that is the fact.)

No application for an inquiry into the mental capacity of the said A. B. has been
made previous to this application.

The petitioner therefore prays that a reception order may be made in accordance
with the foregoing statement.

(Sd.) C. D.

The statements contained or referred to in paragraphs                         are true to my

knowledge; the other statements are true to my information and belief.


(Sd.) C. D.


| If any of the. particulars in this statement is not known, the fact to be so stated!.]

1,   Full name, caste and titles.

2,   Enter the number of completed years*  The petitioner must be at least ^ eighteen
or twenty-one whichever is the age of majority under the law to which the petitioner is

3,   Insert full description of the name and locality of the asylum (mental hospital)
or the name, address and description of the person in charge of the asylum  (mental
hospital) *

4,   A day within 14 days before the date of the presentation of the petition is requisite.

5,   Here state the relationship with the patient.

6,   Here state whether either of the persons signing the medical certificates is a rela-
tive, partner or assistant of the lunatic or of the petitioner and, if a relative of either,
the exact relationship.