Regulations > [Repealed] Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance Appeals by the Independent Tribunal > Annexure A : Consolidated Forms > Form 12 : Withdrawal of an Application for Reconsideration

FORM 12

WITHDRAWAL OF AN APPLICATION FOR RECONSIDERATION

(Regulation 3(7))

[Section 18(1A) of the Social Assistance Act 13 of 2004]

ATTENTION: Regional Executive Manager

South African Social Security Agency

Private Bag X6011

Kimberley

8300

A. PERSONAL DETAILS OF APPLICANT OR BENEFICIARY

Surname:		Full Names:
ID Number:		Nationality:		Date of Birth:	Gender: M	F
Age	Tel No:	Fax No:	Cell No:	Email:	Tel No:
Physical Address
Postal Address

I, the undersigned, hereby withdraw my application for reconsideration dated ............ My reasons for withdrawing the application for reconsideration are as follows:

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

(Signature of applicant or beneficiary or representative)

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

(Date)

E. REPRESENTATIVE'S DETAILS

Name and Surname:
ID Number:			Date of Birth
Age:	Nationality:		Gender:
Telephone No:	Fax No:	Cell No:	Email Address:

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

Regulations

Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance Appeals by the Independent Tribunal

Annexure A : Consolidated Forms

Form 12 : Withdrawal of an Application for Reconsideration

Kimberley