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FORM 3: home and work address of the (South Africa Department of Justice and Constitutional Development)

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Department of Justice and Constitutional Development
1
J62
REPUBLIC OF SOUTH AFRICA
FORM 3
[Regulation 4]
INTERIM PROTECTION ORDER
SECTION 3(2) OF THE PROTECTION FROM HARASSMENT ACT, 2011 (ACT NO. 17 OF 2011)
(*Delete whichever is not applicable)
Take note: In terms of section 10(4) of the Protection from Harassment Act, 2011, the physical,
home and work address of the complainant or related person must be omitted from the
protection order (including any reference to such an address in documents annexed to the
interim protection order), unless the nature of the terms of the order necessitates the
inclusion of the address.
IN THE MAGISTRATE'S COURT FOR THE DISTRICT OF …………….............................……………….
HELD AT ……………………..........…..................…....... APPLICATION NO. ………....................…/………
In the matter between:
………………………………………………………………...............................………...........…….. (Complainant)
AND
………………………………………………………………....................................………...........…. (Respondent)
1. PARTICULARS OF RESPONDENT
Name and surname: …………........................………........…………………………………………………….
Address:………………………………………………………………..............................………………………
…………………………………………………………………………………………...............................………
…………………………………………………………………………………………...............................………
Contact number (telephone number/cellular phone number/facsimile number/e-mail address (whichever is
available)): ........................................………..…………………………………………………...........................….
………………………………………...................................……………………………………………………………
………………………………………………........................................………………………………………………..
2. PARTICULARS OF APPLICATION
The complainant applied for a protection order against the respondent in terms of the Protection from
Harassment Act, 2011 (Act No. 17 of 2011). This court, after considering the application, issued an
interim protection order against the respondent.
J62
Department of Justice and Constitutional Development
2
3. PARTICULARS OF INTERIM PROTECTION ORDER
In terms of the interim protection order:
3.1 The respondent is prohibited by this court from —
(a) engaging in or attempting to engage in harassment of —
*(i) the complainant; and/or
*(ii) the following related person/s:
……………………………………………........................................………………………………..
……………………………………………........................................………………………………..
……………………………………………........................................………………………………..
……………………………………………........................................………………………………..
……………………………………………........................................………………………………..;
*(b) enlisting the help of another person to engage in harassment of the complainant and/or above
related person/s; and/or
*(c) committing any of the following act/s:
(i) ….....…………………………….......…..............................…………………………………………….
….....…………………………….......…..............................…………………………………………….
(ii) ….....…………………………….......…..............................…………………………………………….
….....…………………………….......…..............................…………………………………………….
(iii) ….....…………………………….......…..............................…………………………………………….
….....…………………………….......…..............................…………………………………………….
*3.2 The court imposes the following additional conditions that are necessary to protect and to provide for
the safety and well-being of the complainant or related person/s:
(a) ……………………………………..................................................…………………………………………….
……………………………………..................................................…………………………………………….
(b) ……………………………………..................................................…………………………………………….
……………………………………..................................................…………………………………………….
(c) ……………………………………..................................................…………………………………………….
……………………………………..................................................…………………………………………….
*3.3 The court orders:
*(a)
That a member of the South African Police Service is to seize the following weapon(s):
................................................................................................................................................................
........................................................................................................................................ .......................
*(b)
That a member of the South African Police Service is to accompany the complainant or related
person to the following residence:……………….………………………………..........................…………
……………………................................................................................................................…………….
to supervise the collection of the complainant's or related person's personal property set out in
paragraph 8 of the application for a protection order, and such member is authorised to take all
reasonable steps to effect the collection of the said property.
J62
Department of Justice and Constitutional Development
3
4. The respondent is called upon to show cause on ……………………………… (the return date) at
……………….. (time) at the abovementioned court, why the court should not issue a final protection order.
5. The return date specified in paragraph 4, above, may be anticipated by the respondent on not less than
24 hours’ notice to the applicant and the court.
6. If the respondent does not appear on the return date and if the court is satisfied that —
(a) proper service has been effected on the respondent; and
(b) the application contains prima facie evidence that the respondent has engaged or is engaging in
harassment,
the court must issue a final protection order.
7. A copy of the application of the complainant and the record of any evidence noted during proceedings are
attached for the information of the respondent.
8. In terms of section 16 of the Act the court may make an order as to costs against a party if it is satisfied
that the party in question has acted frivolously, vexatiously or unreasonably.
9. In terms of sections 3(3) and 15(a) of the Protection from Harassment Act, 2011, ………………………
...................................................................(name and surname), who is a *clerk of court/*sheriff/ *peace officer
is hereby directed to serve the interim protection order, a copy of the application for a protection order and the
record of evidence noted on the respondent in accordance with regulation 28 of the Protection from
Harassment Regulations, 2013.
............................................................... ............................................
MAGISTRATE DATE
TAKE NOTE:
(a) A warrant of arrest has been authorised for the arrest of the respondent, the execution of
which is suspended subject to the respondent's compliance with any specified prohibition, condition,
obligation or order contained in this protection order.
(b) A respondent who contravenes any specified prohibition, condition, obligation or order
contained in the protection order is in terms of section 18(1)(a) of the Protection from Harassment
Act, 2011, guilty of an offence and liable on conviction to a fine or imprisonment for a period not
exceeding five years.
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FORM 3: home and work address of the (South Africa Department of Justice and Constitutional Development)

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Completed 25 June 2021

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