Format of Application to the Magistrate under Section 12 of the Protection of Women from Domestic Violence Act, 2005.
As per Section 12 of Domestic Violence Act 2005, the aggrieved person or a Protection Officer or any other person on behalf of the aggrieved person may present an application to the Magistrate seeking one or more relief under the Act. Extracts of Section 12  is as follows:
Section 12 in The Protection of Women from Domestic Violence Act, 2005
12. Application to Magistrate –
(1) An aggrieved person or a Protection Officer or any other person on behalf of the aggrieved person may present an application to the Magistrate seeking one or more reliefs under this Act: Provided that before passing any order on such application, the Magistrate shall take into consideration any domestic incident report received by him from the Protection Officer or the service provider.
(2) The relief sought for under sub-section (1) may include a relief for issuance of an order for payment of compensation or damages without prejudice to the right of such person to institute a suit for compensation or damages for the injuries caused by the acts of domestic violence committed by the respondent: Provided that where a decree for any amount as compensation or damages has been passed by any court in favour of the aggrieved person, the amount, if any, paid or payable in pursuance of the order made by the Magistrate under this Act shall be set off against the amount payable under such decree and the decree shall, notwithstanding anything contained in the Code of Civil Procedure, 1908 (5 of 1908), or any other law for the time being in force, be executable for the balance amount, if any, left after such set off.
(3) Every application under sub-section (1) shall be in such form and contain such particulars as may be prescribed or as nearly as possible thereto.
(4) The Magistrate shall fix the first date of hearing, which shall not ordinarily be beyond three days from the date of receipt of the application by the court.
(5) The Magistrate shall endeavour to dispose of every application made under sub-section (1) within a period of sixty days from the date of its first hearing.
Sample format of Application under Section 12 of The Protection of Women from Domestic Violence Act, 2005 is given below:

IN THE COURT OF JUDICIAL MAGISTRATE AT _________
CASE NO. __________ OF 20__

IN THE MATTER OF:
MRS. W_________                                                            COMPLAINANT
VERSUS
MR. H __________                                                           RESPONDENT
Police Station : _________________

APPLICATION UNDER THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005
MOST RESPECTFULLY SHOWETH:
The Applicant submits as under:
That the Petitioner No. 1 is legally wedded wife of the Respondent.
1. That the Application under Section _________ of Protection of Women from Domestic Violence Act, 2005 is being filed along with copy of Domestic Violence Report by the –
(a) Aggrieve Person       ____
(b) Protection Officer    _____
(c) Any other person on behalf of aggrieved person ___
(tick whichever is applicable)
2. It is prayed that the Hon’ble Court may take cognizance of the Complaint / Domestic incident Report and pass all / any of the orders, as deemed necessary in the circumstances of the case:
(a) Pass protection orders under section 18 and / or
(b) Pass residency order under section 19 and / or
(c) Direct the respondent to pay monetary relief under section 20 and / or
(d) Pass orders under section 21 of the Act and/ or
(e) Pass such interim orders as the court deems just and proper and / or
(g) Pass orders as deems fit in the circumstances of the case.
3. Orders Required

(i) Protection Orders Under Section 18:
[] Prohibiting acts of domestic violence by granting an injunction against the Respondent/s from repeating any of the acts mentioned in terms of column 4(a)/(b) /(c)/ (d)/ (e)/ (f)/ (g) of the Application.
[] Prohibiting Respondent9s) from entering the school/ college/ workplace
[] Prohibiting from stopping the applicant from going to my place of employment
[] Prohibiting Respondent (s) from entering the school / college / any other place of Children of the Applicant.
[] Prohibiting from stopping the applicant from going to my school
[] Prohibiting any form of communication by the Respondent with the Applicant
[] Prohibiting alienation of Assets by the Respondent
[] Prohibiting operation of joint bank lockers/ accounts by the Respondent and allowing the aggrieved person to operate the same.
[] Directing the Respondent to stay away from the dependants/ relative/ any other person of the aggrieved person to prohibit violence against them
[] Any other Conditions, Please specify ________________

(ii) Residence Order Under Section 19
An order restraining Respondent (s) from
[] Dispossessing or throwing out the applicant from the shared household
[] Entering that portion of the shared household in which the applicant resides
[] Alienating/disposing/encumbering the shared household
[] Renouncing his rights in the shared household
[] An order entitling the Applicant continued access to personal effects of the Applicant.
[] An order directing Respondent (s) to
[] Remove himself from the shared household
[] Secure same level of alternate accommodation or pay rent for the same
[] Any other orders, Please Specify _________________

(iii) Monetary Relief under section 20
[]Loss of earnings, amount claimed
[] Medical expenses, amount claimed
[] Loss due to destruction / damage or removal of property from the control of the Aggrieved person, amount claimed ______
[] Any other Loss or physical or mental injury as specified in clause 10 (d), amount claimed ______
[] Total Amount Claimed _______
[] Any other amount, Please Specify _____________

(iv) Monitory Relief under Section 20
[] Directing the Respondent to pay the following expenses as monetary relief
[] Food, Clothes, Medications and other basic amenities ___Amount ___ per Month
[] School fees and related expenses _____ Amount ____ per month
[] Household Expenses _____ Amount _____ per Month
[] Any other Expenses ____ Amount _____ per month
[] Any other orders, please specify _____________________________

(v) Custody order under Section 21
Direct the Respondent to hand over the custody of the child or children to the:
[] Aggrieved person- Applicant
[] Any other person on her behalf, details of such person ________

(vi) Compensation order under Section 22

(vii) Any other order, Please specify ___________________
4. Details of Previous litigation, if any
(a) Under Indian Penal Code, Sections _____ Pending in the Court of _______
Disposed off, Details of Relief ___________
(b)  Under Code of Criminal Procedure, Sections ______ Pending in the Court of ___
Disposed off, Details of Relief ___________
(c)  Under Hindu marriage Act, 1955, Sections ____ Pending in the Court of _____
Disposed off, Details of Relief ___________
(d) Under the Hindu Hindu Adoptions and Maintenance Act, 1956, Sections ___ Pending in the Court of ____
Disposed off, Details of Relief ___________
(e) Application for Maintenance, under section ____ Under _____Act
Interim Maintenance Rs. ________ P.M.
Maintenance Granted Rs. ________ P.M.
(f) Whether Respondent was sent to Judicial Custody
– For Less than a Week
– For Less than a month
– For More than one month
Specify Period ___________________________________
(g) Any other Order __________________________________

P R A Y E R
It is, therefore, most respectfully prayed that this Hon’ble Court be pleased to grant the relief (s) claimed therein and pass such order or orders other order as this Hon’ble Court may deem fit and proper under the give facts and circumstances of the case for protecting the aggrieved person, the Applicant from Domestic Violence and in the interest of Justice.
Place:
Date:

COMPLAINANT / AGGRIEVED PERSON THROUGH COUNSEL VERIFICATION
Verified at ____________ (Place) on this day of ___________ that the contents of Paras 1 to 12 of the above application are true and correct to the best of my knowledge and nothing in Material has been concealed therefrom.
DEPONENT

Note
Application under Section 12 of Domestic Violence Act for protection must be supported with the following Documents.
1. Affidavit of the Applicant
2. Copy of Marriage Certificate
3. Details of cases pending if any between the parties
4. Copy of order for interim or final maintenance order, if applicable
5. Copy of complaint given to police if any