[Repealed by the Second Repealing and Amending Act, 1914 {XVII of 1914), Sec. 3 and Sch. II].
SCHEDULE I FORM I (See Sec. 96) Application for Reception order (See Sees. 5 and 6) In the matter of A. B. [1] residing at........., by occupation............, son of............, a person alleged to be a lunatic.
To......Presidency Magistrate, for...... [or District Magistrate of......, or Sub-Divisional Magistrate of.......or Magistrate specially empowered under Act IV of 1912 for.........].
The petition of C. D. [1], residing at..............., by occupation............, son of.....................
in the town of.................. [or sub-division of...............in the district of...............]
1. I am........ [2] years of age.
2. I desire to obtain an order for the reception of A.B. as a lunatic in the............asylum of............situate at [3].
3. I last saw the said A. B. at.........on the......... ['[day of...........
4. I am the............ [6] of the said A. B.
[or if the petitioner is not relative of the patient state as follows;]
I am not a relative of the said A. B. The reason 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 are [7].
34
6. A statement of particulars relating to the said A. B. accompanies this petition.
7. [if that is the fact.] An application for an enquiry 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 said petition is annexed hereto.
[Or if that is the fact] No application for an enquiry 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 paragraph.....................are true to my knowledge; the other statements are true to my information and belief.
(Sd.) C. D.
Dated:
Statement of particulars [If any of the particulars in this statement is not known, the fact to be so stated.]
The following is a statement of particulars relating to the said A. B:
Name of patient at length.
Sex and age.
Married, single or widowed.
Previous occupation.
Caste and religious belief, as far as known.
Residence at or immediately previous to the date hereof.
Names of any near relatives to the patient who are alive.
Whether this is first attack of lunacy.
Age (if known) on first attack.
When and where previously under care and treatment as a lunatic.
Duration of existing attack.
Supposed cause.
Whether the patient is subject to epilepsy.
Whether suicidal.
Whether the patient is known to be suffering from phthisis or any form of tubercular disease.
Whether dangerous to others, and in what way.
35 Whether any near relative (stating the relationship) has been afflicted with insanity.
Whether the patient (is addicted to alcohol, or the use of opium, ganja, char as, bhang, cocaine or other intoxicant.
[The statements contained or referred to in paras......................are true to my knowledge. The other statements are true to my information and belief.]
Signature by person making the statement.]
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 subject.
3. Insert full description of the name and locality of the asylum or the name, address and description of the person in charge of the asylum.
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.
7. Here state whether either of the persons, signing the medical certificate is a relative, partner or assistant of the lunatic or of the petitioner and, if a relative of either, the exact relationship.
FORM 2 Reception Order on Petition (See Sees. 7, 10) I, the undersigned E. F., being a Presidency Magistrate of...... .............[or the District Magistrate of........................or sub-divisional Magistrate or a Magistrate of the first class specially empowered by Government to perform the functions of a Magistrate under Act IV of 1912] upon the petition of C. D., of [1] in the matter of A.B. [1] a lunatic, accompanied by the medical certificates of G. H., a medical officer, and of J. K., a.
medical practitioner or medical officer, under the said Act, hereto annexed, hereby authorize you to receive the said A. B. into your asylum. And I declare that I have [or have not] personally seen the said A. B., before making this order.
(Sd.) E. F.
(Designation as above.)
To[2] FORM 3 Medical Certificate (See Sees. 18, 19) In the matter of A. B. of [3].........____in the town of..............[or the sub-division of..................in the district of..............................] an alleged lunatic.
I, the undersigned C. D., do hereby certify as follows:
36 gazetted medical officer [or a medical practitioner declared by Government under Act IV of 1912]
1. I am________________________________________________________________ a holder of [4j [or declared by 5[State] Government to be a medical practitioner under Act IV of 1912] and I am in the actual practice of the medical profession.
1. Address and description.
2 To be addressed to the officer or person in charge of the asylum.
3. Insert residence of patient.
4. Insert qualification to practice medicines and surgery registrable in the United Kingdom.
5. Subs, by A.L.O., 1950.
Town
2. On the............day of 19 at [1] in the--------of [or village the sub-division of..............in the district of............ ] [separately from any other practitioner] [2], I personally examined the said A. B. and came to the conclusion that the said A. B. is a lunatic and a proper person to be taken charge of and detained under care and treatment.
3. I formed this conclusion on the following grounds, viz.
(a) Facts indicating insanity observed by myself, viz.:
(b) Other facts (if any) indicating insanity communicated to rne by other, viz. [Here state the information and from whom.]
(Sd.) C. D.
(Designation as above.)
FORM 4 Reception Order in case of lunatic solider (See Sec. 12) Whereas it appears to me that A. B., a European, subject to the Army Act, who has been declared a lunatic in accordance with the provisions of the military regulations, should be removed to an asylum, I do hereby authorize you to receive the said A. B. into your asylum.
(Sd.) E.F.
(Administrative Medical Officer.)
To[3] 37 FORM 5 Reception Order in case of wandering or dangerous lunatics or lunatics not under proper control or cruelly treated (sent to an asylum established by Government) (See Sees. 14, 15, 17) I, C. D., Presidency Magistrate of...................................... [or Commissioner of Police for ] [or the District Magistrate of or the Sub-Divisional Magistrate of ..................or a Magistrate specially empowered by Government under Act IV of 1912] having caused A. B. to be examined by E. F., a Medical Officer under the Indian Lunacy Act, 1912, being satisfied that A.B. [describing him] is a lunatic who was wandering at large ; [or is a person dangerous by reason of lunacy] [or is a lunatic not under proper care and control or is cruelly treated or neglected by the person having the care or charge of him] and a proper person to be taken charge of and detained under care and treatment, hereby direct you to receive the said A. B. into your asylum.
(Sd.) C. D.
(Designation as above) Dated the.........
To the Officer-in-charge of the asylum at............
1. Insert place of examination.
2. Omit this where only one certificate is required.
3. To be addressed to the person in charge of an asylum duly authorized by Government to receive lunatic Europeans subject to the Army Act.
FORM 6 Same when sent to a licensed asylum I, C. D., [as above laid down to "care and treatment"] and being satisfied which the engagement entered into in writing by G. H. of [here insert address and description] who has desired that the said A. B. may be sent to the asylum at .....................[here insert description of asylum end name of the person in charge] to pay the cost of maintenance of the said A. B., in the said asylum, hereby authorize you to receive the said A. B. into your asylum.
(Sd.) C. D.
38 (Designation as above.)
Dated the............
To the person in charge of asylum at .........
FORM 7 Bond on the making over of a lunatic to the care of relative or friend (See Sees. 14, 15, 17) Whereas A, B, son of ..............., inhabitant of......... has been brought up before C. D., a Presidency Magistrate for the town of....................... [or Commissioner of Police for ..........] [or the District/ Sub-Divisional Magistrate of................... or a Magistrate of the first class specially empowered under Act IV of 19121 and is a lunatic who is believed to be dangerous [or deemed to be a lunatic who is not under proper care and control or is cruelly treated or neglected by the person having the charge of him] and whereas I, E. F., son of........., inhabitant of.....................have applied to the Magistrate [or Commissioner of Police], that the said A. B., may be delivered to my care.
E. F., above named hereby bind myself that on the said A. B., being made over to my care, I will have the said A. B. properly taken care of and prevented from doing injury to himself or to others; and in case of my making default therein, I hereby bind myself to forfeit to x [the Government] 2 [* * *] the sum of rupees............
Dated this.........day of..........19 (Sd.) E. F.
(Where a bond with sureties is to be executed add)—We do hereby declare ourselves sureties for the above-named E.F., that he will, on the aforesaid A.B. being made over to his care, have the said A.B. properly taken care of and prevented from doing injury to himself or to others; and in case of the said ' E.F. making default therein, we bind, ourselves, jointly and severally, to forfeit to 1[the Government] 2|* * *] the sum of rupees.......
Dated this.........day of_____19 (Signature) FORM 8 Bond on the discharge of a lunatic from an asylum on the undertaking of relative or friend to take due care (See Sec. 33) Whereas A. B., son of............... inhabitant of......is a lunatic who is now detained in the asylum at.........under an order made by C. D., a Presidency Magistrate for the town 39 of..................... [or Commissioner of Police for............... ... ] [or the District/ Sub- Divisional Magistrate of............................., or a Magistrate of the first class specially empowered under Act IV of 1912] under Sec. 14 lor Sec. 15] of Act IV of 1912, and whereas I, E. F., son of..........................inhabitant of........... ...have applied to the said Magistrate [or Commissioner of Police] that the said A.B. may be delivered to my care and custody.
I hereby bind myself that on the said A. B. being made over to my care and custody, I will have him properly taken care of and prevented from doing injury to himself or to others ; and in case of my making default therein, 1 hereby bind myself to forfeit to 1[the Government] 2[ * * * ] the sum of rupees............
Dated this.........day of...... .....19 (Sd.) E.F.
(Where a bond with sureties is to be executed add) We do hereby declare ourselves sureties for the above-named E. F., that he will, on the aforesaid A. B., being delivered to his care and custody, have the said A. B. properly taken care of and prevented from doing injury to himself or to others; and in case of the said E. F. making default therein, we bind ourselves, jointly and severally, to forfeit to 1[the Government] 2[* * *] the sum of rupees.
Dated this.........day of 19 (Signature)
SCHEDULE II.—Enactment repealed.— Repealed by the Second Repealing and Amending Act, 1914 (17 of 1914), Sec. 3 and Sch. II.
1. Subs, by the A. L. O., 1950, for the words "His Majesty the King".
2. The words "Emperor of India" omitted by the A.L.O., 1948.