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Protection from Harassment Act, 2010 (Act No. 17 of 2010)

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Protection from Harassment Regulations, 2013

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Form 21 [Regulation 23]

 

AFFIDAVIT FOR PURPOSES OF FURTHER WARRANT OF ARREST

SECTION 11 (3) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

 

 

IN THE MAGISTRATE'S COURT FOR THE DISTRICT OF ................................................................................................................................................

 

HELD AT .......................................................................................................................................................... APPLICATION NO............./..............

 

In the matter between:

 

....................................................................................................................................................................................................... (Complainant)

 

AND

.........................................................................................................................................................................................................(Respondent)

 

 

* Delete whichever is not applicable

 

PART A : AFFIDAVIT  (To be completed by complainant)

 

1. COMPLAINANT'S PARTICULARS

 

Surname

Full names:

Identity number/Date of birth:

Home or temporary address:

 

 

Home/contact telephone number/s:

Work address:

 

 

Work telephone number:

Occupation:

 

2. PARTICULARS OF PROTECTION ORDER

 

A protection order was granted and a warrant of arrest authorised on:

(Date)

In the Magistrate's Court at:

Against :

(Name of Respondent)

Application number:

 

3. PARTICULARS OF RESPONDENT

 

Surname

Full names:

Identity number/Date of birth:

Home address:

 

 

Home/contact telephone number/s:

Work address:

 

 

Work telephone number:

 

4. PARTICULARS OF APPLICATION

 

4.1   I require a *second /*further warrant of arrest for my protection.

 

4.2  The existing warrant of arrest has been *executed and cancelled/*lost /*destroyed, under the following circumstances: ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

 

 

______________________________________________

____________________________________

Signature of complainant

Date

 

 

PART B : CERTIFICATION  (for official use)

 

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 / thumb print / mark 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:____________________________________________________________________________________________________________________________________________

 

 

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