Regulations > Protection from Harassment Regulations, 2013 > Annexures

AFFIDAVIT FOR PURPOSES OF FURTHER WARRANT OF ARREST

SECTION 11 (3) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)

IN THE MAGISTRATE'S COURT FOR THE DISTRICT OF ................................................................................................................................................

HELD AT .......................................................................................................................................................... APPLICATION NO............./..............

In the matter between:

....................................................................................................................................................................................................... (Complainant)

AND

* Delete whichever is not applicable

PART A : AFFIDAVIT (To be completed by complainant)

1. COMPLAINANT'S PARTICULARS

Surname
Full names:
Identity number/Date of birth:
Home or temporary address:
Home/contact telephone number/s:
Work address:
Work telephone number:
Occupation:

2. PARTICULARS OF PROTECTION ORDER

A protection order was granted and a warrant of arrest authorised on:	(Date)
In the Magistrate's Court at:
Against :	(Name of Respondent)
Application number:

3. PARTICULARS OF RESPONDENT

Surname
Full names:
Identity number/Date of birth:
Home address:
Home/contact telephone number/s:
Work address:
Work telephone number:

4. PARTICULARS OF APPLICATION

4.1 I require a *second /*further warrant of arrest for my protection.

4.2 The existing warrant of arrest has been *executed and cancelled/*lost /*destroyed, under the following circumstances: ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

______________________________________________	____________________________________
Signature of complainant	Date

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_________________________________________________________

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___________

_____________________________________________

Justice of the Peace / Commissioner of Oaths

Full Names:__________________________________________________________________________________________________________________________________________________

Designation:_________________________________________________________________________________________________________________________________________________

Area for which appointed:_____________________________________________________________________________________________________________________________________

Business Address:____________________________________________________________________________________________________________________________________________

***********************************

Protection from Harassment Act, 2010 (Act No. 17 of 2010)

Regulations

Protection from Harassment Regulations, 2013

Annexures

Form 21 [Regulation 23]