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Promotion of National Unity and Reconciliation Act, 1995 (Act No. 34 of 1995)

Regulations

Regulations relating to Assistance to Victims in respect of Basic Education, 2014

Annexure

Form 1 : Application for assistance in respect of Basic Education

 

FORM 1

 

[Regulation 10]

 

APPLICATION FOR ASSISTANCE IN RESPECT OF BASIC EDUCATION

 

PROMOTION OF NATIONAL UNITY AND RECONCILIATION ACT, 1995 (ACT 34 OF 1995)

 

READ THIS FIRST

Only a person who—

(a) has been found by the Truth and Reconciliation Commission (TRC) to be a victim; or
(b) is a relative, such as the child, or a dependant of a victim, such as a grandchild or spouse, may request assistance.

 

To qualify for assistance—

(a) the household of which the person who needs assistance is a member, must not earn more than R132 000,00 gross income per year; or
(b) the person who needs assistance must be a member of a vulnerable household.

 

A household consists of the spouse, children, grandchildren, parents and grandparents of a victim.

 

A vulnerable household is a household consisting of four or more members, where:

* the majority of members are over the age of 65 years;
* the majority of members are receiving social assistance;
* one member is physically or mentally disabled;
* one of the members is under the age of 18 years and has to work; or
* only one of the members is working;

 

Remember to attach the required documents confirming the information given in this form, for example, certified copies of an identity book and proof of income, otherwise your application will not be considered.

 

 

A. PARTICULARS OF PERSON WHO COMPLETES FORM
1. Title:

(Mr, Miss, Mrs, Dr)
2. Surname:

3. First Names:

4. ID number:

5. Date of birth:

6. Gender:

* Male / Female
7. Contact details:
* Home address / Home address of other person (if applicable):

(State below the address where you live and to which mail may be sent. If you do not have an address, state the address of another person who can be contacted, e.g. place of worship, school, community leader, etc.)

 

 

 

 
* Postal address / Postal address of other person (if applicable):

 

 

 

 

Telephone Numbers:

Home: (         )

Work: (         )

Cell no:

8.

(a) Are you completing this form on behalf of somebody else?

 

*Yes        /        No
(b) If you are completing this form on behalf of somebody else, also complete part B (B1 and B2) below.

9. If you are applying for assistance, complete the following:
(a) Are you a victim?

 

* Yes        /        No
(b) If you are not a victim,

(i) what is the name of the victim?

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

(ii) are you a relative or dependant of a victim?

 

 

* Yes        /        No
(c) If you are a relative or dependant of a victim, what is your relationship with the victim:

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

(for eg. are you the spouse, child, grandchild or sibling of a victim)

10.

(a) If you are applying for assistance, do you have any disability?

 

(b) If yes, give details of the disability:

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

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

 

 

                                                                               

Signature

 

* Yes        /        No

 

 

 

 

 

 

                                   

             Date

 

B.1 PARTICULARS OF PERSON WHO NEEDS ASSISTANCE

Complete this part only if you are applying for assistance on behalf of another person. Indicate here the particulars of the person who needs assistance.
1. Title:

(Mr, Miss, Mrs)
2. Surname:

3. First Names:

4. ID number:

5. Date of birth:

6. Gender:

* Male / Female
7. Contact details:

 
* Home address / Home address of other person (if applicable):

(State below the address where the person who needs assistance lives and to which mail may be sent. If he or she does not have an address, state the address of another person who can be contacted, e.g. place of worship, school, community leader, etc.)

 

 

 

 
* Postal address / Postal address of other person (if applicable):

 

 

 

 

Telephone Numbers:

Home: (        )

Work: (     )

Cell no:
8. Is the person who needs assistance:
(a) A victim?

 

*Yes        /        No
(b) If he or she is not a victim—

(i) what is the name of the victim?

...........................................................................................
(ii) is he or she a relative or dependant of a victim?

*Yes        /        No
(c) If he or she is a relative or dependant of a victim, what is his or her relationship with the victim:

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

(for eg: are you the spouse, child, grandchild or sibling of a victim)

9.

(a) Does the person who needs assistance have any disability?

 

(b) If yes, give details of the disability:

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

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

 

 

                                                                               

Signature of the person completing the form

on behalf of the person who needs assistance

 

* Yes        /        No

 

 

 

 

 

 

                                   

             Date

 

B.2 PARTICULARS OF FINANCIAL ASSISTANCE/AID/CONCESSIONS RECEIVED BY PERSON WHO NEEDS ASSISTANCE

Complete this part only if the person who needs assistance has received any form of assistance from the State, for example, a bursary or any discount or has been exempted from paying school fees. Indicate here the form of assistance and the amount received.
1. Name of the institution / person who granted / is to grant the aid / assistance:

...................................................................................................................................
2. The year for which aid / assistance was received or is to be received:

...................................................................................................................................
3. Nature and amount of the assistance / aid received or is to be received:

...................................................................................................................................
4. Conditions attached to the aid / assistance :

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

(Attach documents to support the above information.)

 

C. FORMS OF ASSISTANCE APPLIED FOR

The forms of assistance include payment of school fees, allowances for the purchasing of school uniforms and boarding and transport allowances.
C.1 ASSISTANCE IN RESPECT OF GRADE R (Reg 5)
I. Assistance in respect of school fees:

 

If assistance is needed in respect of school fees, complete the following:

 

1. Year in respect of which assistance is needed: .......................................................

 

2. Details of School:
(a) Name of School: ...........................................................................................
(b) Address of School: ........................................................................................

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

(Indicate the physical address, in other words, where the centre is situated)

 

3. Total amount of fees payable to school: ..................................................

(Attach proof of enrolment at school and of the amount payable to the school. Indicate whether the amount payable is academic year or term.)

 

4. Banking details of the school in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the school)

Name of bank: ..............................................

Branch code: .................................................

Account number: ..........................................

 
II. Assistance in respect of accommodation:

If assistance is needed in respect of accommodation, complete the following:

 

1. Boarding home Details:

Name of hostel / boarding home: ...............................................................................

Address of hostel / boarding home: ............................................................................

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

(Indicate the physical address, in other words, where the hostel / boarding home is situated.)

 

2. Amount of boarding fees academic year which has to be paid: .........................................

(Attach proof of the amount payable and that the person who needs assistance is hiring accommodation.)

 

3.
(a) Is the school attended/to be attended by the person who needs assistance the nearest school?

* Yes                /        No

(b) If not—

 

(i)        What is the distance between the place of residence of the person who needs assistance and the nearest school?

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

 

(ii) Is there public transport available directly from the place of residence of the person who needs assistances and the nearest school?

* Yes                /        No

 

(iii) If the person who needs assistance cannot be accommodated at the nearest school, indicate why not:
❑ The nearest school is full

or

❑ The person who needs assistance has special needs, namely

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

4. Banking details of the institution / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the hostel/boarding home)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
III. Assistance in respect of purchasing of school uniform:

 

If assistance is needed in respect of the purchasing of a school uniform, complete the following:

 

1. Does the school attended/to be attended by the person who needs assistance require the wearing of a school uniform?        * Yes        /        No

 

2. If yes, amount applied for the school uniform academic year: .....................................

(Attach proof of the amount payable and that the person who needs assistance, is required to wear a school uniform.)

 

3. Banking details of the supplier / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the supplier / person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
IV. Assistance in respect of transport:

 

If assistance is needed in respect of transport, complete the following:

 

1. Method of transport to be used by the person who needs assistance:

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

 

2. Particulars of institution / person providing transport:

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

 

3. Distance between place of residence of the person who needs assistance and school where education is offered:

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

 

4. Amount which has to be paid for transport for the year:

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

 

5. Does the person who needs assistance reside in a school hostel?                        * Yes        /        No

 

6.

(a) Is the school attended / to be attended the nearest school?                        * Yes        /        No
(b) If not, why not:
❑ The nearest school is full

or

❑ The person who needs assistance has special needs, namely

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

 

7. Banking details of the institution  / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the supplier / person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 

 

 

                                                                                                                                       
Signature of applicant or the person completing        Date

the form on behalf of the person who needs assistance

 

 

C.2 ASSISTANCE IN RESPECT OF GENERAL EDUCATION (Reg 6)
I. Assistance in respect of school fees:

 

If assistance is needed in respect of school fees, complete the following:

 

1. Year in respect of which assistance is needed: .......................................................

 

2. Details of School:

Name of School: ...........................................................................................

Address of School: ........................................................................................

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

(Indicate the physical address, in other words, where the school is situated)

 

3. Total amount of fees payable to school: ........................................................

(Attach proof of enrolment at school and of the amount payable to the school. Indicate whether the amount payable is academic year or term.)

 

4. Banking details of the school in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the school)

Name of bank: ..............................................

Branch code: .................................................

Account number: ..........................................

 
II. Assistance in respect of accommodation:

If assistance is needed in respect of accommodation, complete the following:

 

1. Boarding home Details:

Name of hostel / boarding home: ...............................................................................

Address of hostel / boarding home: ............................................................................

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

(Indicate the physical address, in other words, where the hostel / boarding home is situated.)

 

2. Amount of boarding fees academic year which has to be paid: .........................................

(Attach proof of the amount payable and that the person who needs assistance is hiring accommodation.)

 

3.
(a) Is the school attended/to be attended by the person who needs assistance the nearest school?

* Yes                /        No

(b) If not—

 

(i) What is the distance between the place of residence of the person who needs assistance and the nearest school?

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

 

(ii) Is there public transport available directly from the place of residence of the person who needs assistance and the nearest school?

* Yes                /        No

 

(iii) If the person who needs assistance cannot be accommodated at the nearest school, indicate why not:
❑ The nearest school is full

or

❑ The person who needs assistance has special needs, namely

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

4. Banking details of the institution / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the hostel/boarding home)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
III. Assistance in respect of purchasing of school uniform:

 

If assistance is needed in respect of the purchasing of a school uniform, complete the following:

 

1. Does the school attended/to be attended by the person who needs assistance require the wearing of a school uniform?        * Yes        /        No

 

2. If yes, amount applied for the school uniform academic year: .....................................

(Attach proof of the amount payable and that the person who needs assistance, is required to wear a school uniform.)

 

3. Banking details of the supplier / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the institution/ person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
IV. Assistance in respect of transport:

 

If assistance is needed in respect of transport, complete the following:

 

1. Method of transport to be used by the person who needs assistance:

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

 

2. Particulars of institution / person providing transport:

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

 

3. Distance between place of residence of the person who needs assistance and school where education is offered:

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

 

4. Amount which has to be paid for transport for the year:

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

 

5. Does the person who needs assistance reside in a school hostel?                        * Yes        /        No

 

6.

(a) Is the school attended / to be attended the nearest school?                        * Yes        /        No
(b) If not, why not:
❑ The nearest school is full

or

❑ The person who needs assistance has special needs, namely

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

 

7. Banking details of the institution / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the institution / person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 

 

 

                                                                                                                                         
Signature of applicant or the person completing                Date

the form on behalf of the person who needs assistance

 

 

C.3 ASSISTANCE IN RESPECT OF FURTHER EDUCATION (Reg 7)
I. Assistance in respect of school fees:

 

If assistance is needed in respect of school fees, complete the following:

 

1. Year in respect of which assistance is needed: .......................................................

 

2. Details of School:
(a) Name of School: ...........................................................................................
(b) Address of School: ........................................................................................

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

(Indicate the physical address, in other words, where the school is situated)

 

3. Total amount of fees payable to school: ........................................................

(Attach proof of enrolment at school and of the amount payable to the school. Indicate whether the amount payable is academic year or term.)

 

4. Banking details of the school in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the school)

Name of bank: ..............................................

Branch code: .................................................

Account number: ..........................................

 
II. Assistance in respect of accommodation:

If assistance is needed in respect of accommodation, complete the following:

 

1. Boarding home Details:

Name of hostel / boarding home: ...............................................................................

Address of hostel / boarding home: ............................................................................

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

(Indicate the physical address, in other words, where the hostel / boarding home is situated.)

 

2. Amount of boarding fees academic year which has to be paid: .........................................

(Attach proof of the amount payable and that the person who needs assistance is hiring accommodation.)

 

3.
(a) Is the school attended/to be attended by the person who needs assistance the nearest school?

* Yes                /        No

(b) If not—

 

(i)        What is the distance between the place of residence of the person who needs assistance and the nearest school?

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

 

(ii) Is there public transport available directly from the place of residence of the person who needs assistance and the nearest school?

* Yes                /        No

 

(iii) If the person who needs assistance cannot be accommodated at the nearest school, indicate why not:
❑ The nearest school is full

or

❑ Beneficiary has special needs, namely

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

4. Banking details of the institution / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the hostel /boarding home)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
III. Assistance in respect of purchasing of school uniform:

 

If assistance is applied for in respect of the purchasing of a school uniform, please complete the following:

 

1. Does the school attended/to be attended by the person who needs assistance require the wearing of a school uniform?        * Yes        /        No

 

2. If yes, amount applied for the school uniform academic year: .....................................

(Attach proof of the amount payable and that the person who needs assistance, is required to wear a school uniform.)

 

3. Banking details of the supplier / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the supplier / person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 
IV. Assistance in respect of transport:

 

If assistance is needed in respect of transport, complete the following:

 

1. Method of transport to be used by the person who needs assistance:

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

 

2. Particulars of institution / person providing transport:

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

 

3. Distance between place of residence of the person who needs assistance and school where education is offered:

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

 

4. Amount which has to be paid for transport for the year:

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

 

5. Does the person who needs assistance reside in a school hostel?                        * Yes        /        No

 

6.

(a) Is the school attended / to be attended the nearest school?                        * Yes        /        No
(b) If not, why not:
❑ The nearest school is full

or

❑ The person who needs assistance has special needs, namely

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

 

7. Banking details of the institution / person in whose bank account the money is to be paid:

 

Name of Account holder: ..............................

(Bank in question must affix its stamp here to confirm the banking details of the institution / person)

Name of bank:...............................................

Branch code: .................................................

Account number: ..........................................

 

 

 

                                                                                                                                       
Signature of applicant or the person completing        Date

the form on behalf of the person who needs assistance

 

 

D. PARTICULARS OF COMPOSITION OF HOUSEHOLD

A household consists of the spouse, children, grandchildren, parents and grandparents of a victim.
1. Number of members in household:

..........................
2. Number of members in household who are working:

..........................
3. Number of members in household who are over the age of 65 years:

..........................
4. Number of members in household who are receiving social assistance in terms of the Social Assistance Act:

..........................
5. Number of members in household who are physically or mentally disabled as contemplated in section 9 of the Social Assistance Act:

..........................
6. Number of members in household who are working in order to contribute to the income of the household and are under the age of 18 years:

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

(Attach proof in support of the information provided above.)

 

E. PARTICULARS OF INCOME OF MEMBERS OF HOUSEHOLD

Note that it is not necessary to complete this part if assistance in terms of these Regulations has previously been provided to the person who needs assistance.

If the space provided on this page is not enough, complete particulars on a separate page/s and attach additional page/s to this form.

Particulars of income of member(s) of household:

(Indicate whether it is a pension, salary, commission or seasonal and if it is seasonal, give details thereof.)

Member 1:

Full names and Surname:

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

ID no.

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

Gross annual income:

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

Nature of the income:

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

Relationship with victim:

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

Member 2:

Full names and Surname:

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

ID no.

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

Gross annual income:

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

Nature of the income:

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

Relationship with victim:

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

Member 3:

Full names and Surname:

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

ID no.

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

Gross annual income:

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

Nature of the income:

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

Relationship with victim:

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

Member 4:

Full names and Surname:

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

ID no.

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

Gross annual income:

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

Nature of the income:

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

Relationship with victim:

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

 

F. CERTIFICATION

 

I, .................................................................................................................., hereby certify that the information which I have provided above is correct and to the best of my knowledge true. I hereby give permission to the Department of Justice and Constitutional Development to verify the correctness of any of my statements. I know that I can be prosecuted if I knowingly give false information.

 

 

                                                                                                                                       
Signature of applicant or the person completing Date

the form on behalf of the person who needs assistance

 

NOTE

The application form must, after completion, be submitted to the dedicated official—

(a) electronically to the following address: [email protected]: or
(b) by facsimile to 086 641 5744; or
(c) by registered post to the following address: The Head: TRC Unit, The Department of Justice and Constitutional Development, Private Bag X81, Pretoria, 0001.

 

[Form 1 substituted by section 14 of Notice No. R. 1193, GG43890, dated 6 November 2020]