AFFIDAVIT BY MEMBER OF SOUTH AFRICAN POLICE SERVICE TO

FURNISH INFORMATION TO COURT

SECTION 5(3)(a) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

(CONFIDENTIAL)

(MUST BE COMPLETED IN DUPLICATE)

APPLICATION NO ............/20.......

DIRECTION NO ............./20......

To: ............................................................................................................................................. (name and surname of clerk of the court identified in the direction)

From (particulars of person making affidavit): ..................................................................................................................

(Name and surname: ......................................................................................................................................................

Telephone number: ........................................................................................................................................................

Physical address: .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Rank: ..............................................................................................................................................................................

Persal number: ...............................................................................................................................................................

hereby states as follows:

2.        As a result of the investigation the following information of the respondent has been obtained:

2.1        Name and surname of respondent: .........................................................................................................................................................................................................

2.2        Address of respondent: ..........................................................................................................................................................................................................................

2.3        The following additional information has been acquired in order to identify or trace the respondent:

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

(Any documentation acquired which may be used to identify or trace the respondent must be attached as an annexure to this form.)

I certify that before administering the *oath / taking the affirmation I asked the Deponent the following questions and noted *her/his answers in *her/his presence as indicated below: -

(a)        Do you know and understand the contents of the above declaration?

Answer_________________________________________________________

(b)        Do you have any objection to taking the prescribed oath?

Answer_________________________________________________________

(c)        Do you consider the prescribed oath to be binding on your conscience?

Answer_________________________________________________________

I certify that the Deponent has acknowledged that *she/he knows and understands the contents of this declaration which was *sworn to / affirmed before me, and the Deponent's signature was placed thereon in my presence.

Dated at __________________________________________________this ________________________________day of___________________________________________ 20___________

_____________________________________________

Justice of the Peace / Commissioner of Oaths

Full Names:__________________________________________________________________________________________________________________________________________________

Designation:_________________________________________________________________________________________________________________________________________________

Area for which appointed:_____________________________________________________________________________________________________________________________________

Business Address:____________________________________________________________________________________________________________________________________________

To be completed by the clerk of the court on receipt of the affidavit:

I, ............................................................................. (name and surname of clerk of the court), hereby certify that I have received this affidavit from .............................................(name and surname of person who furnished the affidavit to clerk of the court) on ................................. (date).

_______________________________

Signature of clerk of the court

(CONFIDENTIAL)

***********************************