Regulations > Regulations relating to Sheriffs, 1990 > Annexures

I, ........................................................................................................................................................(*full names of claimant/representative of claimant), duly authorised by ......................................................... (full names of claimant), hereby lodge a claim in respect of contingency referred to in section 35 of the Sheriffs Act, 1986 (Act No. 90 of 1986), against the Fidelity Fund for Sheriffs.
A.	PERSONAL PARTICULARS
	(Items 1 to 10 to be completed by or on behalf of a natural person, items 9 to 12 on behalf of a juristic person or partnership and items 13 to 15 by an authorised respresentative of such a person, juristic person or partnership.)
	1.	Sex ..................................................................................................................................................................
	2.	Marital status ...................................................................................................................................................
	3.	Deleted
	4.	Date of birth ......................................................................................................................................................
	5.	Nationality ........................................................................................................................................................
	6.	Identity number ................................................................................................................................................
	7.	Residential address ...........................................................................................................................................
		..........................................................................................................................................................................
		................................................................................................................	Postal code .................................
	8.	Telephone number ............................................................................................................................................
	9.	Work or business address ..................................................................................................................................
		..........................................................................................................................................................................
		.................................................................................................................	Postal code ..................................
	10.	Telephone number ............................................................................................................................................
	11.	Postal address ....................................................................................................................................................
		...........................................................................................................................................................................
		.................................................................................................................	Postal code ..................................
	12.	Telephone number ............................................................................................................................................
	13.	Capacity ..............................................................................................(e.g. attorney/advocate/director/partner)
	14.	Work or business address .....................................................................................................................................
		...........................................................................................................................................................................
		.................................................................................................................	Postal code ..................................
	15.	Telephone number ............................................................................................................................................

* Delete whichever is not applicable.

B.	PARTICULARS of claim
	1.	Place of contingency ..........................................................................................................................................
	2.	Date of contingency ...........................................................................................................................................
	3.	Date when claimant became aware of contingency .............................................................................................
		...........................................................................................................................................................................
	4.	Nature of contingency ........................................................................................................................................
		............................................................................................................................................................................
	5.	Names and addresses of eyewitnesses to contingency
		(a)...............................................................................	.................................................................................... .................................................................................... Postal code ..................................................................
		(b) ..............................................................................	................................................................................... ................................................................................... Postal code ....................................................................................
		(c)................................................................................	.................................................................................... .................................................................................... Postal code ..................................................................
	6.	Name and address of sheriff or deputy sheriff in respect of whom the claim arose
		..............................................................................	.................................................................................... .................................................................................... Postal code..................................................................
	7.	Details of damage or loss suffered ........................................................................................................................
		................................................................................................................. ............................................................
	8.	Total amount claimed ...........................................................................................................................................

I declare that the particulars furnished by me are in all respects complete and correct.

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

Signature of claimant or authorised representative

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

Date

Remarks:

1.	Regulations relating to Sheriffs, 1990, it is an offence to furnish particulars or information or make a statement which is false or misleading.

2.	This claim must be accompanied by the procuration and corroborative documents.

Sheriffs Act, 1986 (Act No. 90 of 1986)

Regulations

Regulations relating to Sheriffs, 1990

Annexures

Form 6 : Claims against Fund [Regulation 5]