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Social Assistance Act, 2004 (Act No. 13 of 2004)

Regulations

Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance Appeals by the Independent Tribunal

Annexure A : Consolidated Forms

Form 1 : Application for Reconsideration

 

FORM 1

 

APPLICATION FOR RECONSIDERATION

(Regulation 2(1))

[Section 18(1) of the Social Assistance Act 13 of 2004]

 

A.        PERSONAL DETAILS OF APPLICANT OR BENEFICIARY

Surname:

Full Names:

ID Number:

Nationality:

Gender:       M

F

Tel No:

Fax No:

Email:

Cell No:

Physical Address

Postal Address

 

B.        DETAILS OF GRANT APPLICATION: AGENCY

Agency Office:

Date of Application:

 

Date of Rejection:

 

Type of Grant (Mark with "X")

Disability

Older

Persons'

War

Veteran

Foster

Child

Care

Dependency

Child

Support

Grant in

Aid

Social

Relief

of

Distress

 

C.        REASONS FOR REQUEST FOR RECONSIDERATION

 

Reasons why you disagree with the decision of the Agency: (If the space provided is insufficient, please attach a separate page to this form. (Please sign and date the separate page).

 

Reasons:

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

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

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

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

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

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

Separate page attached (Please indicate with an X)

YES

NO

 

D.        DOCUMENTATION TO ACCOMPANY APPLICATION

Copy of a letter of rejection or approval of social assistance application by the Agency:

Copy of the power of attorney or letter of appointment by the applicant or beneficiary;

Previous and current medical reports which were presented to the Agency (if available);

Proof of grant application to Agency (Receipt issued by Agency);

Proof of income and/or assets

Any other relevant document in relation to the application; and state what type of documentation).

 

E.        REPRESENTATIVE'S DETAILS

Surname:

Full Names:

ID No:

Nationality:

Gender

Telephone No:

Fax No:

Cell No:

Email address:

 

 

 

 

 

 

 

 

Signature of applicant/beneficiary/representative

 

Place

 

Date

 

 

 

OFFICIAL DATE STAMP OF RECEIPT: