Amendment status not verified — confirm the current text below against the official source.
[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.]