Page 332 - The Motor Vehicles Act, 1988

248 COMPENSATION TO VICTIMS ..........ACCIDENTS SCHEME, 2022 FORM IV

FORM III
[Paragraph 22(1)]
Serial No. ...................
Claims Settlement Commissioner
District .............................................
ORDER
I hereby sanction Rs. …………………... (Rupees ………………………….only) as compensation
in respect of the death of .........(Name of deceased)/grievous hurt to...........(Name
of the injured) resulting from hit and run motor accidents which took place at
...................... (Name of place) on ........................................ (Date) to Shri/Shrimati/
Kumari.......as legal representative of the deceased (......................) or to
.......................................... (Name of injured).
Claims Settlement Commissioner
CC to:—
1. Trust and General Insurance Council
2. The Claimant;
3. Motor Vehicles Accident Claims Tribunals;
4. Claims Enquiry Officer;
5. Member - Secretary of the Standing Committee.

FORM IV
[Paragraph 20(1)]
UNDERTAKING FOR REFUND OF CLAIM
(Under section 163 of the Motor Vehicles Act, 1988)
I/We ................................................................ as legal representative(s) of the
deceased/injured ....................................... hereby give undertaking that I/we shall
refund the amount of compensation that may be awarded to me/us under section
161 of the Act, to the Hit and Run Compensation Fund of the Motor Vehicle
Accident Fund in case I/we am/are awarded any other compensation or amount
in lieu of or by way of satisfaction of a claim for compensation in respect of death
or grievous hurt to ................................. under any other provisions of the Motor
Vehicles Act, 1988 or any other law for the time being in force or otherwise.

Signature of the legal representative
of the deceased/injured person