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Social Assistance Act, 2004 (Act No. 13 of 2004)

Regulations

Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance Appeals by the Independent Tribunal

Annexure A : Consolidated Forms

Form 11 : Withdrawal of an Appeal

 

FORM 11

 

WITHDRAWAL OF AN APPEAL

(Regulation 22)

[Section 18(1A) of the Social Assistance Act 13 of 2004]

 

 

ATTENTION:

Independent Tribunal for Social Assistance Appeals

Private Bag X901, PRETORIA 0001

 

A.        PERSONAL DETAILS OF APPLICANT OR BENEFICIARY

Surname:

Full Names:

ID Number:

Nationality:

Gender:       M

F

Tel No:

Fax No:

Email:

Cell No:

Physical Address

Postal Address

 

I, the undersigned, hereby withdraw my application for an appeal dated ............  My reasons for withdrawing the appeals are as follows:

 

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(Signature of applicant or beneficiary or representative)

 

Date:

 

E.        REPRESENTATIVE'S DETAILS

Name and Surname:

ID Number:

Date of Birth

Age:

Nationality:

Gender:      

 

Telephone No:

 

Fax No:

Cell No:

Email Address: