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Application To Forum For Redressal ofGrievance
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| Date*: __________ |
| 1. Name of the Complainant: ____________________ |
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2. Full address of the Complainant *:________________
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| Pin Code*: _____________ |
| Phone no.*: _____________ |
| Fax no.: ___________ |
| Email id: ___________ |
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3. Nature of Connection and Consumer no.*(incase of having applied for a connection, state the applicationnumber):______________________________________________________________
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4. Division/Sub Division/Section Name*:______________
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5. Complaint receiving centre number*:______________
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6. Category of grievance(please tick therelevant box/ boxes):
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a. Wrong billing___ b. Recovery of arrears ___c. Faulty Meter ___ d. Burnt meter ___e. Supply interruption ___f. Harmonics in supply ___ g. Supply voltage related ___h.Deficient service ___ i. Delay in providing new connection ___ j.Reconnection ___k. Change in connected load ___ l. Transfer ofconnection ___ m. Others(please specify)__________________________________________
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7. Name, designation and office address of theemployee / employees against whom grievance has been filed(ifany):
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| _________________________________________________________________ |
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8. Details of the grievance, facts giving riseto the grievance*(If space is not sufficient please encloseseparate sheet)
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| __________________________________________________________________________ |
| __________________________________________________________________________ |
| __________________________________________________________________________ |
| 9. Nature of relief sought from the Forum |
| __________________________________________________________________________ |
| __________________________________________________________________________ |
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10. List of documents enclosed(Pleaseenclose copies of any relevant documents which support the factsgiving rise to the grievance)
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| _______________________ |
| ________________________ |
| ________________________ |
| 11. Declaration |
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(a) I/ We, the Complainant /s herein declarethat:
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(i) the information furnished herein above istrue and correct; and
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(ii) I/ We have not concealed or misrepresentedany fact stated hereinabove and the documents submitted herewith.
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(b) The subject matter of the present Grievancehas never been submitted to the Forum by me/ or by any one of usor by any of the parties concerned with the subject matter to thebest of my/ our knowledge.
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(c) The subject matter of my / our Grievance hasnot been settled through the Forum in any previous proceedings.
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(d) The subject matter of my / our Grievance hasnot been decided by any competent authority/court/arbitrator, andis not pending before any such authority / court / arbitrator.
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| Yours faithfully |
| (Signature) |
| (Complainant's name in block letters) |
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Nomination- (If the Complainant wants tonominate his representative to appear and make submissions on hisbehalf before the Forum, the following declaration should besubmitted.)
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I/We the above named consumer hereby nominateShri/Smt........................................................... ,whose address is......................................................................................................................................................................................................................................................................................................................................................................................... as my/ourREPRESENTATIVE in the proceedings and confirm that any statement,acceptance or rejection made by him/her shall be binding onme/us. He/She has signed below in my presence.
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| Accepted |
| (Signature of Representative) |
| (Signature of Complainant) |