FORM 5
COMPLAINT REGARDING INTERFERENCE WITH THE PROTECTION OF PERSONAL INFORMATION/COMPLAINT REGARDING DETERMINATION OF AN ADJUDICATOR IN TERMS OF SECTION 74 OF THE PROTECTION OF PERSONAL INFORMATION ACT, 2013 (ACT NO. 4 OF 2013) REGULATIONS RELATING TO THE PROTECTION OF PERSONAL INFORMATION, 2017 [Regulation 7] Note: 1. Affidavits or other documentary evidence in support of the request must be attached.
Details of Data Subject (Complainant)
Surname:
Full Names:
South African ID Number:
Residential / Postal / Business Address:
Telephone:
Fax:
Cellular:
Email Address:
Details of Responsible Party (Alleged Interferer)
Natural Person
Not a Natural Person
Name and Surname:
Residential / Postal / Business Address:
Telephone:
Fax:
Cellular:
Email:
Name of Public/Private Body:
Business Address:
Telephone:
Fax:
Cellular:
Email:
Details of Adjudicator
Natural Person
Not a Natural Person
Name and Surname:
Residential / Postal / Business Address:
Telephone:
Fax:
Cellular:
Email:
Name of Public/Private Body:
Business Address:
Telephone:
Fax:
Cellular:
Email:
Details of Complaint
Date and time of alleged interference (if known):
Describe the alleged interference in detail:
Supporting Documents
Signature
Signed at:
Date:
Upload Signature Image: