Annexure A

PLEASE NOTE:

It is imperative to understand the content of the document entitled GUIDELINES, RULES AND CONDITIONS PERTAINING TO CERTIFICATES ISSUED UNDER PARAGRAPH (A) OF REBATE ITEM 412.11/00.00/01.00 FOR GOODS IMPORTED FOR THE RELIEF OF DISTRESS OF PERSONS IN CASES OF FAMINE OR NATIONAL DISASTER (“the Guidelines”), before completing this application form.

This application must be sent to the following email address: [email protected]. The failure to adhere to this condition may result in a delay in the processing of an application.

If the space provided in this form is insufficient, please use the layout of this application form as a guideline for the format in which the requested information should be submitted.

SWORN AFFIDAVIT

Submit the following declaration by the CEO or duly authorized representative of the company:

I, ____________________________________________________ (full names) with identity number

________________________________, in my capacity as __________________________________

of ______________________________________________ (hereinafter referred to as the applicant)

hereby declare under oath that I am duly authorized to depose hereto and that the information furnished in this application in terms of Rebate Item 412.11(a) for goods being imported for sale to or disposal of solely to persons entitled to privileges, as well as the Excel spreadsheet (Annexure B) and all other representations that form part of the application, are, to the best of my knowledge, true and correct.

I CERTIFY THAT THE DEPONENT HAS ACKNOWLEDGED THAT HE/SHE KNOWS AND UNDERSTANDS THE CONTENTS OF THIS STATEMENT, AND THAT HE/SHE HAS NO OBJECTION TO TAKING THE PRESCRIBED OATH, AND THAT HE/SHE CONSIDERS THIS OATH TO BE BINDING ON HIS/HER CONSCIENCE. THE STATEMENT WAS SWORN TO/ AFFIRMED BEFORE ME AND THAT THE DEPONENTS SIGNATURE WAS PLACED THEREON BEFORE ME.

SIGNED and SWORN to before me at _________________________ this ____ Day of _________ Year_______.

___________________________

COMMISSIONER OF OATHS

FULL NAMES: _______________________________

DESIGNATION: ______________________________

ADDRESS: __________________________________

CHECKLIST

When submitting an application form to ITAC, an applicant is also required to submit the Checklist (Table 1) below. The supporting documents referred to in the Checklist are also set forth in paragraph 4.4 of the Guidelines.

Table 1: Check List