Statistics Act, 1999
R 385
Protection from Harassment Act, 2010 (Act No. 17 of 2010)RegulationsRegulations in terms of the Protection from Harassment Act 2011Annexure : Form 22 [Regulation 24] |
AFFIDAVIT REGARDING CONTRAVENTION OF PROTECTION ORDER
SECTION 11(4)(a) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)
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In the matter between:
....................................................................................................................................................................................................... (Complainant)
AND .........................................................................................................................................................................................................(Respondent) |
*Delete whichever is not applicable
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PART A : AFFIDAVIT (To be completed by complainant) |
1. COMPLAINANT'S PARTICULARS
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Surname |
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Full names: |
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Identity number/Date of birth: |
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Home or temporary address:
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Home/contact telephone number/s: |
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Work address:
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Work telephone number: |
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Occupation: |
2. PARTICULARS OF PROTECTION ORDER
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A protection order was granted and a warrant of arrest authorised on: |
(Date) |
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In the Magistrate's Court at: |
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Against : |
(Name of Respondent) |
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Application number: |
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*A copy of the protection order indicating what orders were made by the court and the original warrant of arrest are attached. *A copy of the protection order and/or the original warrant of arrest cannot be attached for the following reasons:................................................. ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................ |
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A certified copy of the protection order and warrant of arrest were forwarded to the following police station: |
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3. PARTICULARS OF RESPONDENT
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Surname |
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Full names: |
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Identity number/Date of birth: |
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Home address:
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Home/contact telephone number/s: |
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Work address:
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Work telephone number: |
4. INFORMATION REGARDING BREACH OF PROTECTION ORDER
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Date(s) of breach of protection order: |
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Place(s) where breach of protection order took place: |
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Full details on how any specified prohibition, condition, obligation or order contained in the protection order was breached: |
.......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
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Reasons, if any, for believing that imminent harm may be suffered as a result of the breach of the protection order by the respondent: |
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______________________________________________ |
____________________________________ |
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Signature of complainant |
Date |
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PART B : CERTIFICATION (for official use) |
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 /* thumb print / *mark was placed thereon in my presence.
Dated at __________________________________________________this ________________________________day of___________________________________________ 20___________
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Justice of the Peace / Commissioner of Oaths
Full Names:__________________________________________________________________________________________________________________________________________________
Designation:_________________________________________________________________________________________________________________________________________________
Area for which appointed:_____________________________________________________________________________________________________________________________________
Business Address:____________________________________________________________________________________________________________________________________________
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