Regulations > Regulations relating to Assistance to Victims in respect of Higher Education and Training, 2014 > Annexures > Annexure 1

FORM 3

[Regulation 12]

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

(This form must be completed by the dedicated official (an official in the TRC Unit) when a person who has already received assistance in terms of the Regulations for a previous year, wants to receive further assistance.)

A.	PARTICULARS OF APPLICANT (PERSON WHO NEEDS FURTHER ASSISTANCE)

1. Title:

(Mr, Miss, Mrs, Dr)

2. Surname:

3. First Names:

4. ID number:

5. Date of birth:

6. 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 learner who needs assistance live 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:

B.	PARTICULARS OF FINANCIAL ASSISTANCE/AID/CONCESSIONS RECEIVED BY THE PERSON WHO NEEDS FURTHER ASSISTANCE

Complete this part only if the person who needs further assistance has received any form of assistance from the State, including NSFAS or an institution contemplated in the Skills Development Act or his / her employer, for the year for which assistance is now applied for: For example, a bursary or any discount or has been exempted from paying fees. Indicate here the form of assistance and the amount received.

1.	Name of the institution / person who granted / is to grant the aid / assistance: ............................

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

2.	The year for which aid / assistance was received or is to be received: ..........................................

3.	Nature and amount of the assistance / aid received or is to be received:

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

4.	Conditions attached to the aid / assistance:

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

(Attach documents to support the above information.)

C.	PARTICULARS OF FURTHER ASSISTANCE NEEDED

l.	General particulars:

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

2.	Details of higher education and training institution where student will be studying:

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

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

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

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

3.	Qualification/Programme registered for: ............................................................................

4.	Names of subjects to be registered for: ..............................................................................

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

5.	Which of these subjects has the student not passed previously and how many attempts has the student made in respect thereof?

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

6.	Has the student passed 50% of the courses prescribed for the year prior to the year for which he/she needs assistance:

YES

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

8.	Total amount of fees payable to college/university: ............................................................

(Please attach proof of the above information.)

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 per academic year which has to be paid:

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

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

3.	Does the cost of accommodation includes the cost for meals: Yes/No

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: ................................................

III.	Assistance in respect of a device:

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

1.	Has the student previously received assistance in respect of a device: Yes/No

(A devise which has been lost or damaged cannot be replaced – see Regulation 8A (5) and (6)).

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

3.	Particulars of the device to be purchased:

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

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

4.	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.)

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

6.	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: ...............................................

IV.	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 higher education and training institution where student will be studying:

(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: ................................................

V.	Assistance in respect of an assistive device:

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

1.	Did the student previously receive assistance in respect of an assistive device: Yes/No

(a)	Does the student need the assistive device to be replaced because it was stolen or damaged: Yes/No

(b)	If yes, particulars relating to the theft or damage to the first assistive device must be provided:

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

(See Regulation 8B (7)(a), (b) and (c).)

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

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

4.	Particulars of the assistive device to be purchased:

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

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

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

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

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

7.	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: ................................................

VI.	Assistance in respect of human support:

If assistance is needed in respect of 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: ................................................

VII.	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)
Name of bank:..............................................
Account number: ...........................................
Branch code: ................................................

D.	REMARKS BY DEDICATED OFFICIAL

E.	PARTICULARS OF DEDICATED OFFICIAL

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

Name and surname:

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

ID number:

_________________________________

Signature of dedicated official

__________________

Date of Certificate

[Form 3 inserted by section 15 of Notice No. R. 1194, GG43891, dated 6 November 2020]

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 3 : [Regulation 12]