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FORM 15: AFFIDAVIT BY STATION COMMANDER TO FURNISH (South Africa Department of Justice and Constitutional Development)

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Department of Justice and Constitutional Development
1
J120
REPUBLIC OF SOUTH AFRICA
FORM 15
[Regulation 16(4)]
AFFIDAVIT BY STATION COMMANDER TO FURNISH ADDITIONAL
INFORMATION TO COURT
SECTION 5(4)(b) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT N0. 17 OF 2011)
(CONFIDENTIAL)
Note: If this affidavit is, in terms of regulation 16(4)(a) of the Protection from Harassment Regulations,
2013, delivered to the clerk of the court it must be completed in duplicate.
APPLICATION NO. ……………………..……/20 …… DIRECTION NO………….…….……./20……
To: …………………………………………………………………………(name and surname of clerk of the court
identified in the request for further evidence.
Facsimile number:.............……………………………………………..
From: ……………………………………………………………........................…….. (name and surname of station
commander) of ………………………………………...................……………………………. (name of police station)
Facsimile number: ……………………………………………..………
Telephone number: …………………………………………..………..
I, ……………..................................……………………………………………. (name, surname and Persal number),
station commander of the …………………………….......…………………………….. (police station) situated at the
following address……………………………………..........................................................................................……..
………………………………………………………………………………...........................................…………………..
..………………………………………………………………………………………………….., hereby states as follows
in response to the request for additional evidence:
.………………………………………………………………………………………………………………………
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J120
Department of Justice and Constitutional Development
2
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Signature of Deponent Date
I certify that before administering the *oath / taking the affirmation I asked the Deponent the following
questions and noted *her/his answers in *her/his presence as indicated below:-
(a) Do you know and understand the contents of the above declaration? Answer …………...
(b) Do you have any objection to taking the prescribed oath? Answer …………...
(c) Do you consider the prescribed oath to be binding on your conscience? Answer …………...
I certify that the Deponent has acknowledged that *she/he knows and understands the contents of this
declaration which was *sworn to / affirmed before me, and the Deponent's signature was placed thereon in
my presence.
Dated at ………………………………………….……. this ……….. day of ……………….……….. 20………
______________________________________
Justice of the Peace / Commissioner of Oaths
Full Names: …………………………………………………………………………………………………………..
Designation: ………………………………………………………………………………………………………….
Area for which appointed: …………………………………………………………………………………………..
Business Address: ……………………….…………………………………………………………………………
………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………….
*To be completed by the clerk of the court on receipt of the affidavit filed in terms of regulation 16(4)(a)
of the Protection from Harassment Regulations, 2013:
I, …………………………………………………................……………….. (name and surname of clerk of the court),
hereby certify that I have received this affidavit from …………………….......................……………….. (name and
surname of person who furnished affidavit to clerk of the court) on ……………………………. (date).
…………………………………….
Signature of clerk of the court
(CONFIDENTIAL)
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FORM 15: AFFIDAVIT BY STATION COMMANDER TO FURNISH (South Africa Department of Justice and Constitutional Development)

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Completed 20 June 2021

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