APPLICATION BY STATION COMMANDER FOR EXTENSION OF PERIOD

WITHIN WHICH INFORMATION MUST BE PROVIDED TO COURT OR

CANCELLATION OF DIRECTION

SECTION 5(3)(b) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

Note: If this application is, in terms of regulation 15(2)(a) of the Protection from Harassment Regulations, 2013, filed with the clerk of the court it must be completed in duplicate and submitted in duplicate to the clerk of the court

* Mark with a cross whichever is applicable

Application No. ............................/.....................................

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

To: ......................................................................................................................................................................................................................................................................................................

(The clerk of the court)

Facsimile number of clerk of the court:..............................................

From: ...............................................................................................................................................................................................................................................................(*station commander/ *designated member of the South African Police Service of the...........................................................................................................................................................................police station)

Facsimile number of station commander: ............................................................................................................................................................................................................................................

E-mail address of station commander: .............................................................................................................................................................................................................

Phone number of station commander: ............................................................................................................................................................................................................

AFFIDAVIT NO: .........................................../20...............

To be completed by station commander:

1. I hereby apply for—

2. I, ................................................................... (name, surname and Persal number), the station commander of the ........................................ police station, in support of this application hereby states as follows:

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

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 15(2)(a) of the Protection from Harassment Regulations, 2013:

I, ............................................................................. (name  of clerk of the court), hereby certify that I have received this affidavit from .................................................................(name of person who furnished affidavit to clerk of the court) on ................................. (date).

_______________________________

Signature of clerk of the court

***********************************