J122
Department of Justice and Constitutional Development
(iii) The following additional information has been acquired in order to identify and trace the respondent:
…………….………......................................................................…………………………………………….
..........……….………......................................................................………………………………………….
..........……….………......................................................................………………………………………….
..........……….………......................................................................………………………………………….
..........……….………......................................................................………………………………………….
(Any documentation acquired and which may be used to identify or trace the respondent must be
attached as an annexure to this Form.)
*(e) After a reasonable investigation of the matter, I was unable to determine the name or address of the
respondent.
………………………………………… ……………………………………
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: ……………………….…………………………………………………………………………
………………………………………………………………………………………………………………………….
TAKE NOTE:
The original affidavit must be provided to the clerk of the court, at the request of the complainant or clerk of
the court, when the complainant or person applies for an interim protection order in terms of section 2 of the
Protection from Harassment Act, 2011.
To be completed by the clerk of the court on receipt of the affidavit filed in terms of regulation 18(2) 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)
