Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
400Road
AccidentFund
A
I, the third party with the details reflected in paragraph 1 above hereby declare under oath / affirm that I irrevocablyelect in terms of subsection 2(1) of the Road Accident Fund (Transitional Provisions) Act, 2012 that my daim andthe daims(s) of the person(s) identified in paragraph 2 above and in any annexure to this form, arising from theaccident identified in paragraph 3 above, remain subject to the old Act.
Signature of deponent
Date of signature
CERTIFICATION:
I hereby certify that before administrating the oath / taking the affirmation I asked the deponent the followingquestions and noted his I her answers in his / her presence as indicated below:
1. Do you know and understand the contents of the above declaration?
2. Do you have any objection to taking the prescribed oath?
3. Do you consider the prescribed oath to be binding on your conscience?
I hereby certify that the desponent has acknowledged that he / she knows and understands the contents of thisdeclaration which was sworn to / affirmed before me and the deponent's signature was placed thereon in my presence.
Signature of Justice of the Peace /Commissioner of Oaths
Surname
First Names
Designation
Area for which appointed
Business address
Place of signature
Date of signature
Page 3
8 No. 35999 GOVERNMENT GAZETTE, 14 DECEMBER 2012
Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
ANNEXURE B
RoadAccident
Fund
PARTICULARS OF THIRD PARTY
Surname
First names
Date of Birth
Other Identification
Residential address I
ID number
Postal address
Home Telephone
Cell
E-mail
Specify
WorkTelephone
AMOUNTS RECOVERED AND RECEIVED BY THIRD PARTY
a. Indicate the amount recovered from the driver/owner/employer of the driver of the motor vehicle involved in theaccident:
RI II II 1111 IIb. Indicate the amount received as an interim payment in terms of section 17(6) of the old Act
R11111111111c. Indicate the amount paid to suppliers in terms of section 17(5) of the old Act
R11111111111d. Indicate the amount received in terms of the Compensation for Occupational Injuries and Diseases Act, 1993; the
Defence Act, 2002 or any other Act of Parliament governing the South African National Defence Force:
R1 1 -1 1 1 1 T -1 1 1 1
Page 1
STAATSKOERANT, 14 DESEMBER 2012 No. 35999 9
Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
WO
foLop iaII
1. Surname
First names
Date of Birth
Other Identification
I0
9 I%MAI
Rocadent
Fund
A
ID number
Specify
With reference to the amounts recovered or received contemplated in paragraph 2 (a) - (d) above indicate which suchamounts have been recovered or received:
2. Surname
First names
Date of Birth
Other Identification
ID number
Specify
1111 1111 I
1111 1111 II
With reference to the amounts recovered or received contemplated in paragraph 2 (a) - (d) above indicate which suchamounts have been recovered or received:
R
3. Surname
First names
Date of Birth
b.
ID number
Other Identification Specify
With reference to the amounts recovered or received contemplated in paragraph 2 (a) - (d) above indicate which suchamounts have been recovered or received:
Ra. b.
page 2
10 No. 35999 GOVERNMENT GAZETTE, 14 DECEMBER 2012
Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
* o 1S
4. Surname
First names
Date of Birth
Other Identification
10, 0 a.
401111
Ro&lent
Fund
A 0
A
ID number
Specify
With reference to the amounts recovered or received contemplated in paragraph 2 (a) (d) above indicate which suchamounts have been recovered or received:
C.
b.
d.
If more than four persons are represented kindly furnish the details of the additional person(s) in an annexure.
ROAD ACCIDENT FUND CLAIM NUMBER0 (To be completed where a claim has already been lodged with the Road Accident Fund)
page 3
STAATSKOERANT, 14 DESEMBER 2012 No. 35999 11
Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
A .1 ek
000Road
AccidentFund
I, the third party with the details reflected in paragraph I above hereby declare under oath / affirm that the informationfurnished in this form and any annexure to this form is to the best of my belief true and correct.
Signature of deponent
Date of signature
CERTIFICATION:
I hereby certify that before administrating the oath / taking the affirmation I asked the deponent the followingquestions and noted his / her answers in his / her presence as indicated below:
I. Do you know and understand the contents of the above declaration?
2. Do you have any objection to taking the prescribed oath?
3. Do you consider the prescribed oath to be binding on your conscience?
I hereby certify that the desponent has acknowledged that he / she knows and understands the contents of thisdeclaration which was sworn to / affirmed before me and the deponent's signature was placed thereon in my presence.
Signature of Justice of the Peace /Commissioner of Oaths
Surname
First Names
Designation
Area for which appointed
Business address
Place of signature
Date of signaturepage 4
12 No. 35999 GOVERNMENT GAZETTE, 14 DECEMBER 2012
Reproduced by Sabinet Online in terms of Government Printer’s Copyright Authority No. 10505 dated 02 February 1998
