AFFIDAVIT BY MEMBER OF SOUTH AFRICAN POLICE SERVICE TO

FURNISH INFORMATION TO COURT

SECTION 6(3)(b) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

(CONFIDENTIAL)

(MUST BE COMPLETED IN DUPLICATE)

To the clerk of the Magistrate's Court for the district of:

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

From: ..............................................................................................................................................................................................................................................................................(rank, name and surname of member of South African Police Service) .........................................................................................................................................................................................................

Persal number: ......................................................................................................................................................................................................................................................................................

E-mail address: .......................................................................................................................................................................................................................................................................................

Facsimile number: .................................................................................................................................................................................................................................................................................

Telephone number: ................................................................................................................................................................................................................................................................................

Physical address: ......................................................................................................................................................................................................................................................................................

* Delete whichever is not applicable

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

I, ................................................................... (name and surname) whose further particulars appear from the heading of this document state as follows:

(a)        On ................................................................. (date), the complainant made an affidavit that he/ she intends to apply for a protection order against harassment.

(c)        The matter was investigated in terms of section 6(1) of the Protection from Harassment Act, 2011 (Act No. 17 of 2011), with a view to determining the name and address of the respondent.

*(d)         As a result of the investigation the following information of the respondent has been obtained:

(Any documentation acquired and which may be used to identify or trace the respondent must be attached as an annexure to this Form.)

*(e) After a reasonable investigation of the matter, I was unable to determine the name or address of the respondent.

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 18(2) of the Protection from Harassment Regulations, 2013:

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

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

Signature of clerk of the court

(CONFIDENTIAL)

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