Note:

1. Affidavits or other documentary evidence as applicable in support of the objection may be attached.

2. If the space provided for in this Form is inadequate, submit information as an Annexure to this Form and sign each page.

3. Complete as is applicable.

A

DETAILS OF DATA SUBJECT

Name(s) and surname/ registered name of data subject:

Unique Identifier/ Identity Number

Residential, postal or business address:

Code (       )

Contact number(s):

Fax number / E-mail address:

B

DETAILS OF RESPONSIBLE PARTY

Name(s) and surname/ Registered name of responsible party:

Residential, postal or business address:

Code (       )

Contact number(s):

Fax number/ E-mail address:

C

REASONS FOR OBJECTION IN TERMS OF SECTION 11 (1) (d) to ( f ) (Please provide detailed reasons for the objection)

Signed at                                                            on this           day of                            2         .

Signature of data subject/designated person

PERSONAL INFORMATION

Full Names

Identity Number

Capacity in which request is made (when made on behalf of another person)

Postal Address

Street Address

E-mail Address

Contact Numbers

Tel. (B):

Facsimile:

Cellular:

Full names of person on whose behalf request is made (if applicable):

Identity Number

Postal Address

Street Address

E-mail Address

Contact Numbers

Tel. (B)

Facsimile

Cellular

PARTICULARS OF RECORD REQUESTED

Provide full particulars of the record to which access is requested, including the reference number if that is known to you, to enable the record to be located. (If the provided space is inadequate, please continue on a separate page and attach it to this form. All additional pages must be signed.)

Description of record or relevant part of the record:

Reference number, if available

Any further particulars of record

TYPE OF RECORD

(Mark the applicable box with an "X")

Record is in written or printed form

Record comprises virtual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc)

Record consists of recorded words or information which can be reproduced in sound

Record is held on a computer or in an electronic, or machine-readable form

FORM OF ACCESS

(Mark the applicable box with an "X")

Printed copy of record (including copies of any virtual images, transcriptions and information held on computer or in an electronic or machine-readable form)

Written or printed transcription of virtual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc)

Transcription of soundtrack (written or printed document)

Copy of record on flash drive (including virtual images and soundtracks)

Copy of record on compact disc drive(including virtual images and soundtracks)

Copy of record saved on cloud storage server

MANNER OF ACCESS

(Mark the applicable box with an "X")

Personal inspection of record at registered address of public/private body (including listening to recorded words, information which can be reproduced in sound, or information held on computer or in an electronic or machine-readable form)

Postal services to postal address

Postal services to street address

Courier service to street address

Facsimile of information in written or printed format (including transcriptions)

E-mail of information (including soundtracks if possible)

Cloud share/file transfer

Preferred language

(Note that if the record is not available in the language you prefer, access may be granted in the language in which the record is available)

PARTICULARS OF RIGHT TO BE EXERCISED OR PROTECTED

If the provided space is inadequate, please continue on a separate page and attach it to this Form. The requester must sign all the additional pages.

Indicate which right is to be exercised or protected

Explain why the record requested is required for the exercise or protection of the aforementioned right:

FEES

1. A request fee must be paid before the request will be considered.
2. You will be notified of the amount of the access fee to be paid.
3. The fee payable for access to a record depends on the form in which access is required and the reasonable time required to search for and prepare a record.
4. If you qualify for exemption of the payment of any fee, please state the reason for exemption

Reason

Postal address

Facsimile

Electronic communication

(Please specify)

Reference number:

Request received by:

(State        Rank,        Name        And Surname of Information Officer)

Date received:

Access fees:

Deposit (if any):

Personal inspection of information at registered address of public/private body (including listening to recorded words, information which can be reproduced in sound, or information held on computer or in an electronic or machine-readable form) is free of charge. You are required to make an appointment for the inspection of the information and to bring this Form with you. If you then require any form of reproduction of the information, you will be liable for the fees prescribed in Annexure B.

Printed copies of the information (including copies of any virtual images, transcriptions and information held on computer or in an electronic or machine-readable form )

Written or printed transcription of virtual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc)

Transcription of soundtrack (written or printed document)

Copy of information on flash drive (including virtual images and soundtracks)

Copy of information on compact disc drive(including virtual images and soundtracks)

Copy of record saved on cloud storage server

Postal services to postal address

Postal services to street address

Courier service to street address

Facsimile of information in written or printed format (including transcriptions)

E-mail of information (including soundtracks if possible)

Cloud share/file transfer

Preferred language:

(Note that if the record is not available in the language you prefer, access may be granted in the language in which the record is available)

Item

Cost per A4-size page or part thereof/item

Number of pages/items

Total

Photocopy

Printed copy

For a copy in a computer-readable form on:

1. Flash drive

• To be provided by requestor

2. Compact disc

• If provided by requestor
• If provided to the requestor

R40.00

R40.00

R60.00

For a transcription of visual images per A4-size page

Service to be outsourced. Will

depend on the quotation of the

Copy of visual images

service provider

Transcription of an audio record, per A4-size

R24.00

Copy of an audio record

(i)        Flash drive

• To be provided by requestor

R40.00

(ii)        Compact disc

• If provided by requestor

R40.00

• If provided to the requestor

R60. 00

Postage, e-mail or any other electronic transfer:

Actual costs

TOTAL:

Hours of search

Amount of deposit

(calculated on one third of total amount per request)

Name of Bank:

Name of account holder:

Type of account:

Account number:

Branch Code:

Reference Nr:

Submit proof of payment to:

TO:

(Name of data subject)

FROM:

Contact number(s):

Fax number:

E-mail address:

(Name, address and contact details of responsible party)

Full names and designation of person signing on behalf of responsible party:

Signature of designated person

Date: 

PART B

I, 

(full names of data subject) hereby:

Give my consent.

SPECIFY GOODS or SERVICES:

SPECIFY METHOD OF COMMUNICATION:

FAX:

E - MAIL:

SMS:

OTHERS – SPECIFY:

Signed at                                                            on this           day of                            2         .

Signature of data subject/designated person