ANNEXURE

FORM MHCA 41

DEPARTMENT OF HEALTH

NOTICE OF APPEAL TO HIGH COURT JUDGE IN CHAMBERS REGARDING THE DECISION OF THE MASTER OF THE HIGH COURT TO APPOINT OR

NOT TO APPOINT AN ADMINISTRATOR

(Section 60(10) of the Act)

Surname of User ........................................................................................................

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

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

Residential address:

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Surname of applicant: .................................................................................

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

Residential address:

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

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

Relationship between applicant and mental health care User:    (mark with a cross)

Grounds of the appeal:

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Facts on which the appeal is based:

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

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

                   (Applicant)

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

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