Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 39

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ANNEXURE

FORM MHCA 39

DEPARTMENT OF HEALTH

APPLICATION TO MASTER OF HIGH COURT FOR THE APPOINTMENT OF ADMINISTRATOR

(Section 60(1) and (2) of the Act)

Surname of User in respect of whom application is made: ...............................................................

First name(s) of User: ......................................................................................................................

Date of birth: ....................................or estimated age .....................

Gender:

Male

Female

Occupation

.....................................................................................................

Marital status:

Name of applicant: ................................................(print initials and surname)

The above User has been admitted at : ............................................(name of health establishment)

Relationship of applicant to the User: ...........................................

If the applicant is not the spouse or next of kin:

Give reasons why the spouse or next of kin are not making the application:

...........................................................................................................................................

If the spouse or next of kin are available:

What steps have been made to trace the whereabouts of the spouse or next or kin?

...........................................................................................................................................

All medical certificates or relevant reports related to mental health status and the ability of the User to manage his / her own property (enclose and list)

...........................................................................................................................................

............................................................................................................................................

On what grounds do you believe that the User is incapable of managing his / her property?

...........................................................................................................................................

............................................................................................................................................

Have you seen the User within seven days of this application?

Yes

or No

Give details:

...........................................................................................................................................

............................................................................................................................................

Give the particulars and estimated value of the property of the User:

...........................................................................................................................................

What is the annual income of the User?

............................................................................................................................................

Who, in your opinion, would be most suited to be an administrator for the property of the User?

...........................................................................................................................................

Provide further particulars of the person (e.g. relationship with User, occupation):

........................................................................................................................................

Give the name(s) and contact details of people who may be able to provide further information relating to the mental health status of the User:

........................................................................................................................................

Attach proof that a copy of this application has been given to or served on the person in respect of whom this application is made:

......................................................................................................................................

Signature: ............................................................

(applicant)

Date: ....................................

............................................................................

Affidavit to be signed by a Justice of the Peace / Commissioner of Oaths

I, the undersigned and applicant, hereby affirm that:

I am 18 years of age or older: ......................................................................................

I am a relative, being ..................................................................................................

I am not a relative, being ............................................................................................

Signature: ...................................................................................................................

The above statements was solemnly declared or sworn before me at: .............................

The respondent has acknowledged that he / she knows and understands the content of the affidavit which was sworn to / affirmed before me

Print initials and surname: ........................................................................................

Signature: .................................................................................................................

(Justice of the Peace / Commissioner of Oaths)

Date: .........................................................................................................................

Place: ........................................................................................................................

Decision of Master of the High Court in terms of section 60(13) of the Act

Having considered the allegations and facts related to this application, I hereby—

(a)	appoint .................................................................................(name of person) as an interim administrator pending the outcome of an investigation to be conducted;

(b)	appoint .................................................................................(name of person) as the administrator of the above User's property;

(c)	order that an investigation be conducted in terms of section 60(4) of the Act;

(d)	assert that no administrator should be appointed.

Print initials and surname: ...........................................................

Signature: .........................................................................

(Master of the High Court)

Date: ..........................................

Place: ..........................................................

Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 39

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