AFFIDAVIT BY ELECTRONIC COMMUNICATIONS SERVICE

PROVIDER TO FURNISH INFORMATION TO COURT

SECTION 4(1)(b) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

(CONFIDENTIAL)

APPLICATION NO ............/20.......

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

To: ............................................................................................................................................. (name and surname of clerk of the court identified in the direction)

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

From: .........................................................................................................................................(name and surname of designated person) of ....................................................................................................................................................(name of electronic communications service provider)

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

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

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

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

(*Delete whichever is not applicable)

*PART A

I, ................................................................... (name, surname and identity number) employed as a............................................................................................(designation) at ............................................................. (name of electronic communications service provider) situated at the following address ................................................................................................................................................................................................................................................................................................................

hereby states as follows:

*1. With reference to paragraph 5 of the direction, the following information which is available in the records of this electronic communications service provider is hereby provided:

(a)        The electronic communications identity number/s from which the electronic communication/s originated as indicated in paragraph 4.F of the direction, *is/are *was/were assigned to this electronic communications service provider. The particulars of the client to which this /these electronic communications identity number/s  *is/are *was/were assigned are as follows:

(i)        Full names and surname:...........................................................................................................................................................................................

(ii)        Address:....................................................................................................................................................................................................................

(iii)        Identity number:........................................................................................................................................................................................................

(b)        The electronic communications identity number/s, provided in paragraph 4.F of the direction -

*(i)        contacted the electronic communications identity number/s set out in paragraph 4.B of the direction as indicated in the table below:

*2. With reference to paragraph 6 of the direction, the following information which is available in the records of this electronic communications service provider is hereby provided:

* (b)        The electronic communications identity number/s identified under Item (a)(i), is/are assigned to a client of this electronic communications service provider whose particulars are as follows:

3. In terms of section 4(6) of the Protection from Harassment Act, 2011, the respondent was, on (date) (time), by means of (type of electronic communication), which was addressed to the following electronic communications identity number, informed..................................................................................................................... —

(a)        that the information referred to in paragraph/s*1(a)/*1(b)(i)/*1(b)(ii)/*2(a)/*2(b)/*2(c) is to be provided to the court;

(b)        of the reference number of the direction; and

(c)        of the name and address of the court.

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:___________________________________________________________________________________________________________________________________________

* PART B

The following additional information is hereby provided which may be to the assistance of the court to identify the electronic communications identity number/electronic communications service provider/identity/address of the person from which the harassing communication/s originated:

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

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

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

Name and surname: .................................................................................................................................................................................................................................................................

(CONFIDENTIAL)

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