I, ........................................................................................................................................................(*full names of claimant/representative of claimant), duly authorised by .........................................................  (full names of claimant), hereby lodge a claim in respect of contingency referred to in section 35 of the Sheriffs Act, 1986 (Act No. 90 of 1986), against the Fidelity Fund for Sheriffs.

A.

PERSONAL PARTICULARS

(Items 1 to 10 to be completed by or on behalf of a natural person, items 9 to 12 on behalf of a juristic person or partnership and items 13 to 15 by an authorised respresentative of such a person, juristic person or  partnership.)

1.

Sex ..................................................................................................................................................................

2.

Marital status ...................................................................................................................................................

3.

Deleted

4.

Date of birth ......................................................................................................................................................

5.

Nationality ........................................................................................................................................................

6.

Identity number ................................................................................................................................................

7.

Residential address ...........................................................................................................................................

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

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

Postal code .................................

8.

Telephone number ............................................................................................................................................

9.

Work or business address ..................................................................................................................................

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

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

Postal code ..................................

10.

Telephone number  ............................................................................................................................................

11.

Postal address ....................................................................................................................................................

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

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

Postal code ..................................

12.

Telephone number ............................................................................................................................................

13.

Capacity ..............................................................................................(e.g. attorney/advocate/director/partner)

14.

Work or business address .....................................................................................................................................

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

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

Postal code ..................................

15.

Telephone number  ............................................................................................................................................

B.

PARTICULARS of claim

1.

Place of contingency ..........................................................................................................................................

2.

Date of contingency ...........................................................................................................................................

3.

Date when claimant became aware of contingency .............................................................................................

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

4.

Nature of contingency ........................................................................................................................................

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

5.

Names and addresses of eyewitnesses to contingency

(a)...............................................................................

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

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

Postal code ..................................................................

(b) ..............................................................................

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

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

Postal code ....................................................................................

(c)................................................................................

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

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

Postal code ..................................................................

6.

Name and address of sheriff or deputy sheriff in respect of whom the claim arose

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

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

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

Postal code..................................................................

7.

Details of damage or loss suffered  ........................................................................................................................

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

8.

Total amount claimed ...........................................................................................................................................

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

Signature of claimant or authorised representative

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

Date