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Annex 18A: APPLICATION FOR FINANCIAL ASSISTANCE AND/OR REPATRIATION

South African nationals, who, owing to a total lack of means, require financial assistance
and/or repatriation by way of a loan from Public Funds, are requested to complete this
questionnaire.

It has to be clearly understood that this form is designed to establish the facts and that its
completion by the applicant is no assurance that the assistance will in fact be granted.
Attention is drawn to the fact that there is no legal obligation on the State to render financial
assistance or to undertake repatriation.

In the case of a family, a separate form should be completed by each member who is 16
years of age or older.
__________________________________________________________________________

A. PERSONAL PARTICULARS

1. Full name (block letters) _______________________________________________

___________________________________________________________________

2. Identity number ______________________________________________________

3. Sex _______________________________________________________________

4. Address: Present ____________________________________________________

___________________________________________________________________

In South Africa ______________________________________________________

___________________________________________________________________

5. Birth: Place ________________________________________________________

Date ______________________________________________________________

6. Passport (enclose if available)

(a) Number _____________________________________________________

(b) Place of issue ____________________________________________________

(c) Date of issue _____________________________________________________

(d) Valid until ______________________________________________________

(e) Particulars of any other travel document of South African or foreign origin which
has been issued to you ________________________________________________

7. Particulars of your claim to South African citizenship _________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

8. Do you also have a claim to any other nationality?

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___________________________________________________________________

If so, furnish details ___________________________________________________

___________________________________________________________________

9. Marital status (unmarried/married/widowed/divorced) ________________________

B. PARTICULARS OF SPOUSE (IF YOU ARE MARRIED AND HE/SHE IS NOT

ACCOMPANYING YOU)

10. Full name (block letters) _______________________________________________

__________________________________________________________________

11. Permanent address __________________________________________________

__________________________________________________________________

12. Birth: Place ________________________________________________________

Date ______________________________________________________________

13. Citizenship _________________________________________________________

C. PARTICULARS OF CHILD(REN) IF ACCOMPANYING YOU

14. Full names Age Place of birth

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

D. GENERAL PARTICULARS

15. Furnish full particulars of the nature of the assistance you require
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

and the amount of money you require ____________________________________

___________________________________________________________________

16. Give details of your financial position with full particulars of funds and other
possessions at your disposal at present

___________________________________________________________________

___________________________________________________________________

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___________________________________________________________________

___________________________________________________________________

17. Furnish full particulars of the circumstances which have led to your being in financial
distress ____________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

18. Where did you reside during the last five years of your stay in the Republic?

(a) from ________________ to ________________ at ___________________

(b) from ________________ to ________________ at ___________________

(c) from ________________ to ________________ at ___________________

(d) from ________________ to ________________ at ___________________

(e) from ________________ to ________________ at ___________________

19. When last did you leave the Republic? ____________________________________

20. For what purpose did you leave the Republic? ______________________________

___________________________________________________________________

21. How did you acquire the means to leave the Republic?

___________________________________________________________________

___________________________________________________________________

22. How have you been occupied since leaving South Africa (e.g. vacationing, touring,
working, etc)? Indicate dates or periods.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

23. If it was your intention to return to the Republic, how did you intend to obtain the
funds necessary for your return?

___________________________________________________________________

___________________________________________________________________

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___________________________________________________________________

___________________________________________________________________

24. Why are these funds not available now? __________________________________

___________________________________________________________________

25. Indicate how you propose repaying the loan, if approved.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

26. Furnish full particulars of funds which may still accrue to you.
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

27. If you are in receipt of a pension, indicate the source and monthly amount. If it is a
disability pension, indicate the nature and degree of your disability.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

28. If you receive any help or assistance, furnish full particulars.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

29. What is your normal occupation? ________________________________________

30. If you are employed at present, state the nature of your work, the salary/wages
earned, and the name and address of your employer.
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

31. How do you propose to maintain yourself on your return to the Republic? (e.g. what
work do you propose doing, is a post awaiting you, and if so, what is its nature, the
salary/wage that it commands, is the position temporary or permanent, what will the
name and address of your employer be; if no position is awaiting you, furnish the
name/s and address/es of the person/s who might be prepared to support you.)

___________________________________________________________________

32. Names and addresses of persons in the Republic who might possibly support your

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application and from whom enquiry may be made.

(a) ________________________________________________________________

___________________________________________________________________

(b) ________________________________________________________________

___________________________________________________________________

(c) ________________________________________________________________

___________________________________________________________________

(d) ________________________________________________________________

___________________________________________________________________

(e) ________________________________________________________________

___________________________________________________________________

(Underline the names of those who might be prepared to give you financial
assistance or to guarantee repayment.)

33. Names and addresses of at least three relatives in the Republic. State the
relationship (e.g. parents, brothers, sisters).

(a) ________________________________________________________________

___________________________________________________________________

(b) ________________________________________________________________

___________________________________________________________________

(c) ________________________________________________________________

___________________________________________________________________

(d) ________________________________________________________________

___________________________________________________________________

34. Documents in your possession which may serve to support any part of this
application should be listed here and should be attached to this application ______

___________________________________________________________________

___________________________________________________________________

I DECLARE THAT THE FOREGOING ANSWERS AND DECLARATIONS ARE, TO THE

BEST OF MY KNOWLEDGE AND BELIEF, CORRECT.

Signature: ____________________________________________________

Place: ____________________________________________________

Date: ____________________________________________________

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