Heard About What Happened From Someone

SAHRC Complaint Form FOR OFFICIAL USE Case Number ...................................... Date Received...................................... Received by ........................................ Acknowledged date ............................. Acknowledged by ................................

Please read the complaint pamphlet and the note at the back of this form before filling in this form. Please write clearly and use CAPITAL LETTERS. If there is not enough space on this form for your answer, please use a separate piece of paper and send it to us together with this form.

Note: if there is more than one person who would like to send a complaint to the SAHRC, write the details of these people on a separate form or photocopy this form. Be sure to include all the information asked for in the form for each of these people.

YOUR DETAILS (Everyone completing this form must fill in 1 - 6) Mrs, Ms, Mr?.................... Surname .....................................................................................

1. Your name First name(s) ..........................................................................................................................

2. Your ID number ID number.............................................................................................................................. If you do not have an ID number, what is your date of birth? ............................................... If you do not know your date of birth, how old are you? .....................................................

3. Your race Only fill this in if you think it is important to your case (if you have been unfairly treated because of your race). ............................................................................................................

4. Female/Male Only fill this in if you think it is important to your case 1 Female 0 Male

5.Your address and telephone number(s) The address where you live: ................................................................................................. ............................................................................................................................................... Postal Code ............................................................................................................................

The address we can send letters to: ....................................................................................... ............................................................................................................................................... Postal Code ............................................................................................................................

Telephone number at home: Code ............. Number ............................................................. Telephone number at work: Code ............. Number.............................................................. Is there any other telephone number we can call you at? Code ............. Number .......................................................................................................... Whose telephone number is this? ......................................................................................... Fax number Code ............. Number ...................................................................................... Cellular phone Number .........................................................................................................

6. What language would you like us to write to you in?................................................... ...............................................................................................................................................

The following questions must be filled in if you are writing for somebody else or for an organisation. If your own rights were violated, then do not fill in this page.

7. If this complaint is for someone else, please tell us about him or her Mrs, Ms, Mr?.................... Surname ..................................................................................... First name(s) .............................................................................................. ...........................

8. Their ID number ID number ............................................................................................................................. If they do not have an ID number, what is their date of birth? .............................................. If they do not know their date of birth, how old are they? ....................................................

9. Their race Only fill this in if you/they think it is important to their case (If they have been unfairly treated because of their race). ................................................................................................

10. Are they female or male? Only fill this in if you/they think it is important to their case 0 Female 0 Male

11. Their address and telephone number(s) The address where they live: ................................................................................................. ............................................................................................................................................... Postal Code ...........................................................................................................................

The address we can send letters to: ....................................................................................... ............................................................................................................................................... Postal Code ...........................................................................................................................

Telephone number Code ............. Number ........................................................................... Fax number Code ............. Number ......................................................................................

12. What language would they like us to write to them in? ............................................. ...............................................................................................................................................

13.If this complaint is for an organisation, please tell us: The name of the organisation ................................................................................................ What does it do (e.g., Civic, NGO, Business, retailer, factory) ........................................... Who should we talk to there? ............................................................................................... What is their position (e.g. Colleague, Chairperson, Director, Secretary) .........................................

The address we can send letters to: ....................................................................................... ............................................................................................................................................... Postal Code ............................................................................................................................

Telephone number Code ............. Number ........................................................................... Fax number Code ............. Number ......................................................................................

TELL US ABOUT WHAT HAPPENED 14. Is the problem still happening? 0 Yes 0 No

15. If yes, on what date did it happen? Day ........……… month ........……………………….. Year ............................................ What time? ............................................................................................................................

16. Where did it happen? Town ...........................................................Province ..........................................................

17. Which rights in the Bill of Rights were violated? ....................................................... ............................................................................................................................................... ...............................................................................................................................................

18. Please tell us the name or names of who violated these rights? If you know ........... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

19. Where can we contact them? ....................................................................................... ...............................................................................................................................................

20. If you do not know their names, please tell us anything you do know about them ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

21.In your own words, tell us exactly what happened. Include all the information, which you think is important. Be as brief as possible. If you need more space, please use a separate piece of paper ........................................................................................................................ ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

22. Have you reported this case to anyone else? 0 Yes 0 No If yes, who? (E.g., the police; a lawyer; the Public Protector)............................................... ...............................................................................................................................................

23. Can we use your name in news reports or letters we write for you? 0 Yes 0 No ........................................................................................................................

24. Did anybody see what happened? (Please only tell us about people who actually saw what happened. Do not tell us about people who heard about what happened from someone else.) Their name or names.............................................................................................................. ............................................................................................................................................... How and where can we get in touch with them? .................................................................. ...............................................................................................................................................

25. Please tell us how you heard about the SAHRC (radio advert, newspaper, poster, from a friend, from an NGO or CBO) ..............................................................................

Your Signature: .....................................................................................................................

Date: ......................................................................................................................................

Thank you for filling in this form. We will get back to you as soon as possible. If you have any queries, please call us and ask to speak to someone in the Legal Department.

Note: We may put some of the information you give on this complaints form onto a computer. This helps us monitor progress and produce statistics. We may also give information to the other party in the case (that is the person or people who violated your rights). If you do not want any of your details given out, please answer ‘NO’ to question number 23.

What to do once you have filled in the form. Once you have filled in this form, please post or fax it to us at: Johannesburg - Private Bag 2700, Houghton 2041 Tel: 011 - 484 8300 Fax: 011 - 484 1360

Free State - P O Box 4245, Bloemfontein 9300 Tel: 051 - 447 1130 Fax: 051 447 1128

Eastern Cape - P O Box 1854, Port Elizabeth 6001 Tel: 041 - 582 4094/2611 Fax: 041 - 582 2204

KwaZulu Natal - P O Box 1456, Durban 4000 Tel/Fax: 031- 304 7323/4/5

Northern Province - P O Box 55796, Pietersburg 0700 Tel: 015 - 291 3500/3504 Fax: 015 - 291 3505

Western Cape - P O Box 3563, Cape Town 8001 Tel: 021 - 426 2277 Fax: 021 - 426 2875

North West

P O Box 9586 Rustenburg 0300

Tel (014) 592 0694

Fax (014) 594 1089

Mpumalanga P O Box 6574 Nelspruit 1200 Tel (013) 752-8292 Fax (013) 752-6890

If you fax this form, please post it to us as well.