Fillable FORM C: AUTHORIZATION BY A MEMBER OF THE (South Africa Department of Justice and Constitutional Development)

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FORM C: AUTHORIZATION BY A MEMBER OF THE (South Africa Department of Justice and Constitutional Development)

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Department of Justice and Constitutional Development
REPUBLIC OF SOUTH AFRICA
FORM C
AUTHORIZATION BY A MEMBER OF THE FAMILY OR HOUSEHOLD OR A
DEFENDANT OF A WITNESS OR PROSPECTIVE WITNESS OR OF SUCH A
MEMBER TO BE DETAINED IN OR PLACED UNDER PROTECTIVE CUSTODY
1. I,.................................................................................................................................................................., a)
a ................................................................................................................................................................., b)
of ................................................................................................................................................................, c)
hereby give authorization that I -
* (i) be detained in protective custody;
or
* (ii) be placed under protective custody.
2. I have the following physical injuries:
……...............................................................................................................................................................
……...............................................................................................................................................................
……...............................................................................................................................................................
.................................................................................................................................................................... d)
3. I, ................................................................................................................................................................... ,
hereby declare that the above-mentioned information is, to the best of my knowledge, true, complete and
correct and that I am aware of the fact that it is an offence if I wilfully furnish information or make a
statement which is false or misleading.
.................................................................................
(Signature/mark/thumbprint of deponent)
4. I,………………………………………............................................................................................................... ,
*parent/guardian of the above-mentioned person hereby give authorization for the above-mentioned
person to be so protected.
.................................................................................
(Signature/mark/thumbprint of parent/guardian)
Department of Justice and Constitutional Development
FORM C - AUTHORIZATION BY A MEMBER OF THE FAMILY OR HOUSEHOLD OR A DEFENDANT OF A
WITNESS OR PROSPECTIVE WITNESS OR OF SUCH A MEMBER TO BE DETAINED IN OR PLACED
UNDER PROTECTIVE CUSTODY
Page 2 of 3
5. I, ...................................................................................................................................................................,
hereby certify that I have interpreted truly and to the best of my abilities correctly in relation to the contents
of this statement and any question put to the deponent by the member.
........................................................................
(Signature of interpreter)
........................................................................
(Full name)
.......................................................................
[Designation (Rank)]
......................................................................
......................................................................
......................................................................
......................................................................
(Address of employment)
6. I, ................................................................................................................................................................... ,
hereby certify that before the deponent affixed
* his/her mark, thumbprint or signature to this form, I read
the statement to
* him/her and informed * him/her that it is an offence wilfully to furnish information or make
a statement which is false or misleading.
........................................................................
(Signature of officer)
........................................................................
(Full name)
.......................................................................
[Designation (Rank)]
........................................................................
........................................................................
.......................................................................
........................................................................
(Address of employment)
Department of Justice and Constitutional Development
FORM C - AUTHORIZATION BY A MEMBER OF THE FAMILY OR HOUSEHOLD OR A DEFENDANT OF A
WITNESS OR PROSPECTIVE WITNESS OR OF SUCH A MEMBER TO BE DETAINED IN OR PLACED
UNDER PROTECTIVE CUSTODY
Page 3 of 3
Remarks:
a) State the name of the member of the family or household of the witness or prospective witness
who requires protection.
b) State relationship to witness or prospective witness.
c) State name of witness or prospective witness.
d) Attach medical certificate (if available).
* Delete whichever is not applicable.
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FORM C: AUTHORIZATION BY A MEMBER OF THE (South Africa Department of Justice and Constitutional Development)

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Completed 21 June 2021

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