AFFIDAVIT BY STATION COMMANDER TO FURNISH ADDITIONAL

INFORMATION TO COURT

SECTION 5(4)(b) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

(CONFIDENTIAL)

Note: If this affidavit is, in terms of regulation 16(4)(a) of the Protection from Harassment Regulations, 2013, delivered to the clerk of the court it must be completed in duplicate.

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

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

To: ............................................................................................................................................. (name and surname of clerk of the court identified in the request for further evidence)

Facsimile number: .........................................................................................................................................................

From ...........................................................................................................................................(name and surname of station commander) of ................................................................................................................................................... (name of police station)

Facsimile number: .........................................................................................................................................................

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

I, ........................................................................................................................................................................................................................................................... (name, surname and Persal number), station commander of the ..................................................................................................................................................................................................................................................(police station) situated at the following address ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................,hereby states as follows in response to the request for additional evidence:

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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 filed in terms of regulation 16(4)(a) of the Protection from Harassment Regulations, 2013:

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  affidavit to clerk of the court) on ................................. (date).

_______________________________

Signature of clerk of the court

(CONFIDENTIAL)

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