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Guidelines:

1 Name Mention Complete Name of the Survivor.
*
2 Address Mention Complete address of the Survivor for Correspondence.
*
3 state Odisha  
4 District Select the name of the district
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5 Pin No. PIN CODE of victim's locality. (If Available)  
6 Email Mention Your Survivor's Email ID for Correspondence . (If Available)
*
7 Phone Mention Phone / Mobile Number of the Survivor for Correspondence.(If Available)  
*
8 Sex Select Gender of the Survivor from the list.
*
9 Date of Birth Mention the Date of birth of the Survivor.
*
10 Whether Challenged Person Select the disability status of the victim from the list.
*
11 Religion Select Religion of the Survivor the list.
*
12 Caste Select Caste of the Survivor from list.
*

Details of the Complainant (Your Details)

13 Name Mention Your Complete Name.
*
14 Address Mention Complete address for Correspondence.
*
15 state    
16 District Select name of your District from the list.
*
17 Pin No. PIN CODE of your locality.
*
18 Email Mention Your Complete Email ID for Correspondence .
*
19 Phone Mention Your Phone / Mobile Number for Correspondence
*
20 sex Select Gender of the Complainant from the list.
*

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