PETITION FOR JUDICIAL SEPARATION
IN THE DISTRICT COURT AT....................
........................................................................ Petitioner
versus 
..................................................................... Respondent
Petition for a judicial separation under Section 10 of the Hindu Marriage Act, 1955 (No. 25 of 1955).
The petitioner prays as follows: —
1. A marriage was solemnized between the parties on.................... at .................... A certified extract from the Hindu Marriage Register/an affidavit duly attested is filed herewith.
2. The status and place of residence of the parties to the marriage before the marriage 
 (i) Before marriage
(ii) At the time of filing the petition
Husband									Wife
Status										Status
Age										Age
Place of Residence								Place of Residence

[Whether a party is a Hindu by religion or not is a part of his or her status.]
3. [In this paragraph particulars and place(s) of co-habitation as husband and wife and the children from the marriage, if any, may be given. The date and place of birth and name and sex of each child and the fact whether alive or dead should also be stated].
4. The respondent has.................... [any one or more of the grounds specified in Section 10 may be pleaded here. The matrimonial offences charged should be set in separate paragraphs with the times and places of their alleged commission. The facts on which the claim to relief is founded should be stated as distinctly as the nature of the case permits. If adultery is pleaded the petitioner should give particulars, as nearly as he can, of the acts of adultery alleged to have been committed].
5. [Where the ground of petition is the ground specified in Section 13(l)(i), the petitioner should state that he has not in any manner been accessory to or connived at or condoned the act(s) complained of].
6. [Where the ground of petition is cruelty]. The petitioner has not in any manner condoned the cruetly.
7. The petition is not presented in collusion with the respondent.
8. There has not been any unnecessary or improper delay in filing this petition.
9. There is no other legal ground why the relief should not be granted.
10. There has not been any previous proceedings with regard to the marriage by or on behalf of any party.
Or
There have been the following previous proceedings with regard to the marriage by or on behalf of the parties: —
Serial No.	Name of Parties	Name of Proceedings with section of the Act	Number and date and year of the case	Name and location of the court	Result
	
(i)						
(ii)						
(iii)						
(iv)						

11. The marriage was solemnized at........................................
Or
The husband and wife resided at........................................
Or
The husband and wife last resided together at.................... within the local limits of the ordinary original civil jurisdiction of this Court.
12. The petitioner, therefore, prays for a decree for judicial separation against the respondent.
Petitioner
VERIFICATION
The abovenamed petitioner states on solemn affirmation that Paras................... to.................... of the petition are true to the best of the petitioner’s information and belief.
Verified on this................. day of.................... 19.................... at....................
Place.................... Petitioner