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 [Repealed] Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance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 3

LODGING OF AN APPEAL

(Regulation 14(1))

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

Agency Office:				Date of Application:		Date of Rejection:
Date of Application For Reconsideration:				Date of Rejection of Application for reconsideration
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

Copy of Identity Document;

Proof of application for reconsideration to Agency;

A copy of a letter of rejection or approval of application for reconsideration by the Agency

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

OFFICIAL DATE STAMP OF RECEIPT:

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 3 : Lodging of an Appeal