Regulations > Regulations relating to Assistance to Victims in respect of Higher Education and Training, 2014 > Annexures > Annexure 1 > Form 1 : Application for assistance in respect of Higher Education and Training

FORM 1

APPLICATION FOR ASSISTANCE IN RESPECT OF HIGHER EDUCATION AND TRAINING

[Regulation 11]

PROMOTION OF NATIONAL UNITY AND RECONCILIATION ACT, 1995 (ACT 34 OF 1995)

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Only a person who—

(a)	has been found by the Truth and Reconciliation Commission (TRC) to be a victim; or

(b)	is a relative, such as the child, or a dependant of a victim, such as a grandchild or spouse, may request assistance.

To qualify for assistance—

(a)	the household of which the person who needs assistance is a member, must not earn more than R198 000,00 gross income per year; or

(b)	the person who needs assistance must be a member of a vulnerable household.

A household consists of the spouse, children, grandchildren, parents and grandparents of a victim.

A vulnerable household is a household consisting of four or more members, where:

*	the majority of members are over the age of 65 years;

*	the majority of members are receiving social assistance;

*	one member is physically or mentally disabled;

*	one of the members is under the age of 18 years and has to work; or

*	only one of the members is working;

Remember to attach the required documents confirming the information given in this form, for example, certified copies of an identity book and proof of income, otherwise your application will not be considered.

A.	PARTICULARS OF PERSON WHO COMPLETES FORM

Title:

(Mr, Miss, Mrs, Dr)

Surname:

3.	First Names:

4.	ID number:

5.	Date of birth:

Gender:

* Male / Female

7.	Highest level of Education:

8.	Contact details:

*	Home address / Home address of other person (if applicable):

(State below the address where you live and to which mail may be sent. If you do not have an address, state the address of another person who can be contacted, e.g. place of worship, school, community leader, etc.)

*	Postal address / Postal address of other person (if applicable):

Telephone Numbers:

Home: ( )

Work: ( )

Cell no:

(a)	Are you completing this form on behalf of somebody else?

*Yes / No

(b)	If you are completing this form on behalf of somebody else, also complete part B (B1 and B2) below.

10.	If you are applying for assistance, complete the following:

(a)	Are you a victim?

* Yes / No

(b)	If you are not a victim,

(i)	what is the name of the victim?

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

(ii)	are you a relative or dependant of a victim?

* Yes / No

(c)	If you are a relative or dependant of a victim, what is your relationship with the victim:

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

(for eg. are you the spouse, child, grandchild or sibling of a victim)

11.

(a)	If you are applying for assistance, do you have any disability?

(b)	If yes, give details of the disability:

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

Signature

* Yes / No

Date

B.1	PARTICULARS OF PERSON WHO NEEDS ASSISTANCE

Complete this part only if you are applying for assistance on behalf of another person. Indicate here the particulars of the person who needs assistance.

Title:

(Mr, Miss, Mrs)

Surname:

3.	First Names:

4.	ID number:

5.	Date of birth:

Gender:

* Male / Female

7.	Highest level of Education:

8.	Contact details:

*	Home address / Home address of other person (if applicable):

(State below the address where the person who needs assistance lives and to which mail may be sent. If he or she does not have an address, state the address of another person who can be contacted, e.g. place of worship, school, community leader, etc.)

*	Postal address / Postal address of other person (if applicable):

Telephone Numbers:

Home: ( )

Work: ( )

Cell no:

9.	Is the person who needs assistance:

(a)

A victim?

*Yes / No

(b)	If he or she is not a victim,

(i)	what is the name of the victim?

(ii)	is he or she a relative or dependant of a victim?

*Yes / No

(c)	If he or she is a relative or dependant of a victim, what is his or her relationship with the victim:

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

10.

(a)	Does the person who needs assistance have any disability?

(b)	If yes, give details of the disability:

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

Signature of the person completing the form on behalf of the person who needs assistance

* Yes / No

Date

C.	FORMS OF ASSISTANCE APPLIED FOR

Note that assistance will only be provided in respect of programmes leading to a qualification. The forms of assistance include fees (registration costs, tuition fees, costs relating to student counselling, work placement and other administrative costs), boarding and transport allowances, a meal allowance, an allowance to purchase textbooks and an assistive device, an allowance for human support in a case of a person with a disability, an allowance to purchase a device such as a laptop, an amount to settle a debt at a college or a higher education institution incurred prior to the 2015 academic year, an amount to settle a fee debt, incurred during the 2015 academic year and the date of commencement of these Regulations at a college or a higher education institution and an allowance when a person works as part of his or her learnership or apprenticeship.

C.1	ASSISTANCE IN RESPECT OF ADULT EDUCATION AND TRAINING (Reg 5)

Note that the highest level of education offered in terms of category C.1 is similar to Grade 9.

Note further that this form of assistance can only be rendered if you are sixteen years of age or older.

I.	Assistance in respect of fees and texbooks:

If assistance is needed in respect of fees and textbooks, complete the following:

1.	Year in respect of which assistance is needed: .............................

2.	Details of centre:

(a)	Name of centre: ..................................................................

(b)	Address of centre................................................................

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

(Indicate the physical address, in other words, where the centre is situated.)

3.	Total amount of fees payable to centre: .......................................

(Attach proof of registration at centre and of the amount payable to the centre. Indicate whether the amount payable is academic year or subject or module.)

4.	Amount needed to purchase textbooks: ......................................

5.	Banking details of the centre in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank: ..............................................
Branch code: .................................................
Account number: ..........................................

II.	Assistance in respect of transport:

If assistance is needed in respect of transport, complete the following:

1.	Method of transport to be used by the person who needs assistance:

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

2.	Particulars of institution / person providing transport: ...............

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

3.	Distance between place of residence of the person who needs assistance and centre where programme is offered:

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

4.	Amount which has to be paid for transport for the year:

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

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank:...............................................
Branch code: .................................................
Account number: ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

C.2	ASSISTANCE IN RESPECT OF FURTHER EDUCATION AND TRAINING (Reg 6)

I.	Assistance in respect of fees:

If assistance is needed in respect of fees, complete the following:

1.	Year in respect of which assistance is needed: .............................

2.	Details of college:

(a)	Name of college: ................................................................

(b)	Address of college: .............................................................

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

(Indicate the physical address, in other words, where the college is situated.)

3.	Are the studies in respect of which assistance is needed, to be done on a full-time or part-time basis or through distance learning?

*Full-time

/Part-time /Distance Learning

4.	Total amount of fees payable to college: ......................................

(Attach proof of registration at centre and of the amount payable to the centre. Indicate whether the amount payable is academic year or subject or module.)

5.	Banking details of the college in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank: ..............................................
Branch code: .................................................
Account number: ..........................................

II.	Assistance in respect of accommodation:

If assistance is needed in respect of accommodation, complete the following:

1.	Boarding home Details:

Name of hostel / boarding home: ..........................................................

Address of hostel/boarding home: ........................................................

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

(Indicate the physical address, in other words, where the hostel is situated)

2.	Amount of boarding fees academic year which has to be paid: ....................

(Attach proof of the amount payable and that the person who needs assistance, is hiring accommodation)

3.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank: ..............................................
Branch code: .................................................
Account number: ..........................................

III.	Assistance in respect of transport:

If assistance is needed in respect of transport, complete the following:

1.	Method of transport to be used by the person who needs assistance:

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

2.	Particulars of institution/person providing transport: ...........................

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

3.	Distance between place of residence of the person who needs assistance and college where programme is offered: .........................................................................

4.	Amount which has to be paid for transport for the year: .......................

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank: ..............................................
Branch code: .................................................
Account number: ..........................................

IV.	Assistance in respect of textbooks:

If assistance is needed in respect of textbooks, complete the following:

1.	Amount needed to purchase text books: ............................................

2.	Particulars of the text books to be purchased: ....................................

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

(Indicate the name of the author, the title of the book and the price of each book.)

3.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the centre)
Name of bank: ..............................................
Branch code: .................................................
Account number: ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

V.	Assistance in respect of meals:

If assistance is needed in respect of meals, complete the following:

1.	The cost of accommodation includes the cost for meals: Yes/No

2.	For how many months in the year is the allowance needed: ................

3.	How often should the allowance be paid: ............................................

4.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VI.	Assistance in respect of a device:

If assistance is needed in respect of a device, complete the following:

1.	Amount needed to purchase a device: ................................................

2.	Particulars of the text books to be purchased: ....................................

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

(Indicate the name, make, model and price of the device.)

3.	Module and Diploma/Degree/Programme registered for:

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

(If you require assistance of more than R7 000,00 to purchase a device that is mandatory for your programme, learning or training, please ensure that the motivation for the device by the head of the college on a letter head of the college is attached.)

4.	Name and Address of college registered with: .....................................

5.	Banking details of the college/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the college/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VII.	Assistance in respect of the settling of a debt:

If assistance is needed in respect of the settling of a debt, complete the following:

1.	Amount of the outstanding debt : ...........................................................

(Proof of the debt and the amount thereof must be attached)

2.	In respect of which year is the amount due: ...........................................

3.	For which qualification is the amount due: .............................................

4.	Details of the College:

(a)	Name of college: ........................................................................

(b)	Address of college: ....................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	The person whose debt needs to be settled will be allowed to register with the college in the next academic semester or year after the settlement: Yes /No.

(Proof of this statement must be attached).

6.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VIII.

Assistance in respect of an assistive device:

If assistance is needed in respect of the assistive device, complete the following:

1.	Amount needed to purchase an assistive device: ...................................

(Attach proof of the amount and of the fact that the assistive device is needed)

2.	Particulars of the assistive device to be purchased: ....................................

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

(Indicate the name, make, model and price of the assistive device.)

3.	Module and Diploma/Degree/Programme registered for and which requires the above assistive device: .........................................................................................

4.	Name and Address of college registered with: ............................................

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

(a)	Name of college: ............................................................................

(b)	Address of college: ........................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	Banking details of the person / institution in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the person/institution)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

IX.	Assistance in respect of human support:

If assistance is needed in respect of the human support, complete the following:

1.	Amount needed for human support: ..............................................................

2.	Details of the human support needed: ...........................................................

3.	Particulars of the person providing human support: .......................................

4.	The person providing human support will be staying with the student: Yes /No

5.	For how many months in the year is the allowance needed: ...........................

6.	Banking details of the person /institution in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

X.	Assistance in respect of the settling of a fee debt:

If assistance is needed in respect of the settling of a fee debt, complete the following:

1.	Amount of the outstanding fee debt: .............................................................

(Proof of the fee debt and the amount thereof must be attached.)

2.	In respect of which year is the amount due: ....................................................

3.	For which qualification is the amount due: ......................................................

4.	Details of the College:

(a)	Name of College: ................................................................................

(b)	Address of College: .............................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	The person whose fee debt needs to be settled will be allowed to register with the College in the next academic semester or year after the settlement: Yes /No.

(Proof of this statement must be attached.)

6.	Banking details of the College in which bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

C.3	ASSISTANCE IN RESPECT OF HIGHER EDUCATION (Reg 7)

Note that the assistance in C.3 is for persons who have passed grade 12 and want to study at a university or technicon. Note further that the assistance is limited to undergraduate students only.

I.	Assistance in respect of fees:

If assistance is needed in respect of fees, complete the following:

1.	Year in respect of which assistance is needed: ..................................................

2.	Details of institution:

(a)	Name of institution: ................................................................................

(b)	Address of institution: .............................................................................

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

(Indicate the physical address, in other words, where the institution is situated.)

3.	Are the studies in respect of which assistance is needed, to be done on a full-time or part-time basis or through distance learning?

*Full-time

/Part-time /Distance Learning

4.	Total amount of fees payable to institution: .....................................................

(Attach proof of registration at centre and of the amount payable to the centre. Indicate whether the amount payable is academic year or subject or module.)

5.	Banking details of the college in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

II.	Assistance in respect of accommodation:

If assistance is needed in respect of accommodation, complete the following:

1.	Boarding home Details:

Name of hostel / boarding home: ..........................................................

Address of hostel/boarding home: ........................................................

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

(Indicate the physical address, in other words, where the hostel/boarding home is situated)

2.	Amount of boarding fees academic year which has to be paid: ....................

(Attach proof of the amount payable and that the person who needs assistance, is hiring accommodation)

3.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/ person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

III.	Assistance in respect of transport:

If assistance is needed in respect of transport, complete the following:

1.	Method of transport to be used by the person who needs assistance:

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

2.	Particulars of institution/person providing transport: .............................

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

3.	Distance between place of residence of the person who needs assistance and institution where programme is offered: ................................................................

4.	Amount which has to be paid for transport for the year: .........................

(Attach proof of the amount and of the fact that the person who needs assistance, makes use of this method of transport.)

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

IV.	Assistance in respect of textbooks:

If assistance is needed in respect of textbooks, complete the following:

1.	Amount needed to purchase text books: ............................................

2.	Particulars of the text books to be purchased: ....................................

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

(Indicate the name of the author, the title of the book and the price of each book.)

3.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

V.	Assistance in respect of meals:

If assistance is needed in respect of meals, complete the following:

1.	The cost of accommodation includes the cost for meals: Yes/No

2.	For how many months in the year is the allowance needed: ................

3.	How often should the allowance be paid: ............................................

4.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VI.	Assistance in respect of a device:

If assistance is needed in respect of a device, complete the following:

1.	Amount needed to purchase a device: ................................................

2.	Particulars of the text books to be purchased: ....................................

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

(Indicate the name, make, model and price of the device.)

3.	Module and Diploma/Degree/Programme registered for:

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

4.	Name and Address of Institution registered with: .................................

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VII.	Assistance in respect of the settling of a debt:

If assistance is needed in respect of the settling of a debt, complete the following:

1.	Amount of the outstanding debt : ...........................................................

(Proof of the debt and the amount thereof must be attached)

2.	In respect of which year is the amount due: ...........................................

3.	For which qualification is the amount due: .............................................

4.	Details of the institution:

(a)	Name of institution:....................................................................

(b)	Address of institution: .................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	The person whose debt needs to be settled will be allowed to register with the institution in the next academic semester or year after the settlement: Yes /No.

(Proof of this statement must be attached).

6.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VIII.

Assistance in respect of an assistive device:

If assistance is needed in respect of the assistive device, complete the following:

1.	Amount needed to purchase an assistive device: ...................................

(Attach proof of the amount and of the fact that the assistive device is needed)

2.	Particulars of the assistive device to be purchased: ....................................

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

(Indicate the name, make, model and price of the assistive device.)

3.	Degree registered for and which requires the above assistive device:

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

4.	Name and Address of institution registered with: .......................................

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

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

IX.	Assistance in respect of human support:

If assistance is needed in respect of the human support, complete the following:

1.	Amount needed for human support: ..............................................................

2.	Details of the human support needed: ...........................................................

3.	Particulars of the person providing human support: .......................................

4.	The person providing human support will be staying with the student: Yes /No

5.	For how many months in the year is the allowance needed: ...........................

6.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

X.	Assistance in respect of the settling of a fee debt:

If assistance is needed in respect of the settling of a fee debt, complete the following:

1.	Amount of the outstanding fee debt: .............................................................

(Proof of the fee debt and the amount thereof must be attached.)

2.	In respect of which year is the amount due: ....................................................

3.	For which qualification is the amount due: ......................................................

4.	Details of the Institution:

(a)	Name of Institution: ........................................................................

(b)	Address of Institution: ....................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	The person whose fee debt needs to be settled will be allowed to register with the Institution in the next academic semester or year after the settlement: Yes /No.

(Proof of this statement must be attached.)

6.	Banking details of the Institution in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

C.4	ASSISTANCE IN RESPECT OF SKILLS DEVELOPMENT (Reg 8)

C.4.1

ASSISTANCE IN RESPECT OF LEARNERSHIP OR APPRENTICESHIP

Note that a person whose application for assistance has been approved will only receive the allowance of R1500,00 per month (Reg 8(1)(c)) during the work experience component of the learnership or apprenticeship for which he or she is registered and if he or she complies with the conditions of the learnership agreement entered into with the employer in terms of the Skills Development Act.

I.	Assistance in respect of fees:

If assistance is needed in respect of fees, complete the following:

1.	Year in respect of which assistance is needed: ..................................................

2.	Details of learnership or apprenticeship for which assistance is needed:

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

3.	Details of college:

(a) Name of college: ................................................................................

(b) Address of college: .............................................................................

(Indicate the physical address, in other words, where the college is situated.)

4.	Total amount of fees payable to college: ..............................................................

(Attach proof of registration at college and of the amount payable to the college. Indicate whether the amount payable is academic year or subject or module.)

5.	Banking details of the college in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the college)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

II.	Allowance payable during work experience component of learnership or apprenticeship:

If the allowance payable during the work experience component of a learnership or apprenticeship must be paid to the person who needs assistance, complete the following:

1.	Period for which the allowance must be paid: .....................................................

2.	Details of employer where the person who needs assistance will be working:

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

Name of the employer: .......................................................................................

Physical address of the employer: .......................................................................

3.	Contact particulars of the employer:

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

Cellphone number: .............................................................................................

Fax number: .........................................................................................................

4.	Banking details of the college in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the College)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

III.	Assistance in respect of meals:

If assistance is needed in respect of meals, complete the following:

1.	The cost of accommodation includes the cost for meals: Yes/No

2.	For how many months in the year is the allowance needed: ................

3.	How often should the allowance be paid: ............................................

4.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

IV.	Assistance in respect of a device:

If assistance is needed in respect of a device, complete the following:

1.	Amount needed to purchase a device: ................................................

2.	Particulars of the device to be purchased: ...........................................

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

(Indicate the name, make, model and price of the device.)

3.	Module and Diploma/Degree/Programme registered for:

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

4.	Name and Address of Institution registered with: .................................

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

VII.	Assistance in respect of an assistive device:

If assistance is needed in respect of the assistive device, complete the following:

1.	Amount needed to purchase an assistive device: ...................................

(Attach proof of the amount and of the fact that the assistive device is needed)

2.	Particulars of the assistive device to be purchased: ....................................

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

(Indicate the name, make, model and price of the assistive device.)

3.	Programme registered for and which requires the above assistive device:

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

4.	Name and Address of institution registered with: .......................................

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

5.	Banking details of the institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: .................................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

IX.	Assistance in respect of human support:

If assistance is needed in respect of the human support, complete the following:

1.	Amount needed for human support: ..............................................................

2.	Details of the human support needed: ...........................................................

3.	Particulars of the person providing human support: .......................................

4.	The person providing human support will be staying with the student: Yes /No

5.	For how many months in the year is the allowance needed: ...........................

6.	Banking details of the institution/person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

X.	Assistance in respect of the settling of a fee debt:

If assistance is needed in respect of the settling of a fee debt, complete the following:

1.	Amount of the outstanding fee debt: .............................................................

(Proof of the fee debt and the amount thereof must be attached.)

2.	In respect of which year is the amount due: ....................................................

3.	For which qualification is the amount due: ......................................................

4.	Details of the Institution:

(a)	Name of Institution: ........................................................................

(b)	Address of Institution: ....................................................................

(Indicate the physical address, in other words, where the institution is situated.)

5.	The person whose fee debt needs to be settled will be allowed to register with the Institution in the next academic semester or year after the settlement: Yes /No.

(Proof of this statement must be attached.)

6.	Banking details of the Institution / person in whose bank account the money is to be paid:

Name of Account holder: ..............................	(Bank in question must affix its stamp here to confirm the banking details of the institution/person)
Name of bank: ..............................................
Account number: ..........................................
Branch code: ..... ..........................................

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

D.	PARTICULARS OF COMPOSITION OF HOUSEHOLD

A household consists of the spouse, children, grandchildren, parents and grandparents of a victim.

1.	Number of members in household:	..........................
2.	Number of members in household who are working:	..........................
3.	Number of members in household who are over the age of 65 years:	..........................
4.	Number of members in household who are receiving social assistance in terms of the Social Assistance Act:	..........................
5.	Number of members in household who are physically or mentally disabled as contemplated in section 9 of the Social Assistance Act:	..........................
6.	Number of members in household who are working in order to contribute to the income of the household and are under the age of 18 years:	..........................

(Attach proof in support of the information provided

E.	PARTICULARS OF INCOME OF MEMBERS OF HOUSEHOLD

Note that it is not necessary to complete this part if assistance in terms of these Regulations has previously been provided to the person who needs assistance.

If the space provided on this page is not enough,complete particulars on a separate page/s and attach additional page/s to this form.

Particulars of income of member(s) of household:

(Indicate whether it is a pension, salary, commission or seasonal and if it is seasonal, give details thereof.)

Member 1:	Full names and Surname:	.......................................................
	ID no.	.......................................................
	Gross annual income:	.......................................................
	Nature of the income:	.......................................................
	Relationship with victim:	.......................................................
Member 2:	Full names and Surname:	.......................................................
	ID no.	.......................................................
	Gross annual income:	.......................................................
	Nature of the income:	.......................................................
	Relationship with victim:	.......................................................
Member 3:	Full names and Surname:	.......................................................
	ID no.	.......................................................
	Gross annual income:	.......................................................
	Nature of the income:	.......................................................
	Relationship with victim:	.......................................................
Member 4:	Full names and Surname:	.......................................................
	ID no.	.......................................................
	Gross annual income:	.......................................................
	Nature of the income:	.......................................................
	Relationship with victim:	.......................................................

F.	CERTIFICATION

I, ............................................................................................................., hereby certify that the information which I have provided above is correct and to the best of my knowledge true. I hereby give permission to the Department of Justice and Constitutional Development to verify the correctness of any of my statements. I know that I can be prosecuted if I knowingly give false information.

Signature of applicant or the person completing

Date

the form on behalf of the person who needs assistance

NOTE

The application form must, after completion, be submitted to the dedicated official—

(a)	electronically to the following addresses: [email protected]; or

(b)	by facsimile to 086 641 5744; or

(c)	by registered post to the following address: The Head: TRC Unit, The Department of Justice and Constitutional Development, Private Bag X81, Pretoria, 0001.

[Form 1 substituted by regulation 12 of Notice No. 1373, GG 42101, dated 14 December 2018]

Promotion of National Unity and Reconciliation Act, 1995 (Act No. 34 of 1995)

Regulations

Regulations relating to Assistance to Victims in respect of Higher Education and Training, 2014

Annexures

Annexure 1

Form 1 : Application for assistance in respect of Higher Education and Training