The Director General : Department of Justice and Constitutional Development
I hereby request and authorise you to pay any amounts in respect of Guardians Fund which may accrue to me to the credit of my / our account with
the authorised financial services provider mentioned below.
I understand that the credit transfers hereby authorised will be processed electronically to the account specified below. I also understand that any
banking costs for transactions (withdrawals/bank statements/etc.) made on the account will be borne by me. The Department of Justice &
Constitutional Development will not be liable for any banking costs on the account. I also hereby indemnify the Department of Justice &
Constitutional Development for any incorrect detail and information that may have been specified on this form.
I,….………………………………………………………………………………………………….….. the undersigned, declare under oath /
affirm and say that I am entitled to the funds claimed herein and that the particulars stated in this application are true and correct to
the best of my knowledge and belief.
I also undertake to inform the Department of Justice & Constitutional Development should any of the above details change in any
way.
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DATE PRINT NAME AND SURNAME
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I certify: SIGNATURE OF APPLICANT
1. that I have satisfied myself as to the identity of the applicant;
2. that the deponent has acknowledged that he / she knows and understands the contents of the affidavit which was signed
before me;
3. That the affidavit was sworn to / affirmed before me at ………………………………………………..……….
on this …………………………..….. day of ……………………………………….… 20 …………………..
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Commissioner of Oaths Signature
Full names: …………………………………………………………………………………………………….…………………………
SAPS Official Force Number (If applicable): ……………………………………………………………………………………………
Area for which appointed: …………………………………………………………………………………………………………...….
Officio ex officio: …………………………………………………………………………………………………………………………..
Address: ………………………………………………………………………….………………………………………………………..