Regulations > Regulations relating to the Lodging of Applications for Social Assistance Appeals and the Consideration and Adjudication of Appeals by the Independent Tribunal issued in terms of Section 32, read with Section 18 of the Act > Annexures

FORM 1

LODGING OF AN APPEAL

(Regulation 12(1))

Section 18 of the Social Assistance Act, 2004 (Act No. 13 of 2004)

For office use only:

Province:

Local Office:

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 AND APPLICATION FOR RECONSIDERATION

(SASSA) Agency Office:
Date of Application Review:				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 APPEAL

Reasons why you disagree with the decision of the Agency: (If the space provided is insufficient, please attach a separate page to this form and clearly indicate that a separate page(s) is attached).

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

D.	DOCUMENTATION TO ACCOMPANY APPEAL

A copy of identity document if the applicant or beneficiary;

A copy of the decision issued by the Agency in relation to the grant application of an applicant or grant review of a beneficiary.

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

Name of the hospital/clinic that you normally attend.

Proof of income and/or assets: Yes No N/A

In the case of a person appealing on behalf of the beneficiary or applicant, a copy of the power of attorney or proof of his or her appointment by the applicant or beneficiary to act on his or her behalf;

Any other relevant supporting documents (state what type of documentation).

E. REPRESENTATIVE'S DETAILS

Name and Surname
Name of Organisation/ Firm (where applicable)
ID Number
Telephone No:	Fax No:	Cell No:	Email Address:


Signature of applicant/beneficiary/representative		Place		Date

F. CONSENT

I hereby provide consent in terms of section 13 and section 20 of the Protection of Personal Information Act, 2013 (Act No. 4 of 2013) that the Independent Tribunal for Social Assistance Appeals may request information from any person / institution which is necessary for the determination of my appeal


Signature of applicant/beneficiary/representative		Place		Date

OFFICIAL DATE STAMP OF RECEIPT:

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

Regulations

Regulations regulating to the Lodging of Applications for Social Assistance Appeals and the Consideration and Adjudication of Appeals by the Independent Tribunal issued in terms of Section 32, read with Section 18 of the Act

Annexures

Form 1 : Lodging of an Appeal