Annexure A

 

                                     ANNEXURE "A"

 

                                                                                 

                                                                               

 

                                                                                                                                     Case no:_____2012              

 

In the matter between:

 

                                                                                                                                    Plaintiff

 

 

and

 

                                                                                                                                                                Defendant

______________________________________________________________________________

 

                    REGULATION 2 OF THE MEDIATION IN CERTAIN DIVORCE MATTERS

                                                              REGULATIONS, 1990

                     ARRANGEMENTS REGARDING DEPENDENT AND MINOR CHILDREN

______________________________________________________________________________

 

 

1.         PARTICULARS OF PLAINTIFF/APPLICANT:

 

1.1       Postal Address:

 

1.2       Residential Address:

           

 

1.3       Telephone Number:

                   

1.4     Name & Address of Employer:

           

1.5     Telephone Number:

         

1.6     Gross Monthly Income:

 

1.7     Extent of Monthly Financial Commitments:

Water & Electricity

Lodging

Groceries

Policies

Motor vehicle instalment

Insurance

 

 

2.         PARTICULARS OF DEFENDANT

 

 

2.1       Postal Address:

           

2.2       Residential Address:

 

2.3       Telephone Number:

 

2.4       Name & Address of Employer:

 

2.5       Telephone Number:

 

2.6       Gross Monthly Income, if known:

 

2.7       Extent of Monthly Financial Commitments, if known:

Unknown

 

3.         GENERAL INFORMATION:

 

3.1       State the full name, gender and date of birth of each minor dependant child of the marriage:

 

3.2       State with whom the children are living at present:

 

3.3       State where the children are to live furnish particulars of the accommodation, what other persons (name them) are living there and who will look after the children. If it is proposed that the children should be in the care of a person other than yourself, state whether or not that person has agreed to this arrangement. State the relationship of such other person to the children:

 

 

3.4       State the name of the school of other educational establishment which your children are at present attending or, if any of them are already working their place of employment, the nature of their work and details of any training they are receiving. Attach copies of the most recent school reports:

 

 

3.5       Is the envisaged that the children, after the conclusion of the action/application, will have to change schools? If so, give full details:

 

 

3.6       Do any of the children experience learning problems? Are any of them in any respect physically or mentally disabled? If so, give full details and attach recent medical reports:

 

 

3.7       State who is supporting the children at present, or contribution to their support, and to what extent:

 

 

3.8       What arrangements have been made regarding rights of contact of your husband/wife? State the details of any of such arrangements:

 

 

3.9       Set out any further details concerning your minor or dependent children which may be relevant to the custody of, access to and financial provision for such children, e.g. whether any such children have been convicted if any criminal offence or whether any such children have been subject to any order in terms of the Child Care Act, 1983, (Act No 74 of 1983).

 

 

3.10     State briefly the extent to which the above arrangements regarding your minor or dependent children are the result of mutual agreement with your husband/wife:

 

           

3.11     Are you or a member of your family known to a welfare organisation or agency? If so, state the name of the organisation agency and where it operates:

 

 

 

DATED AT          THIS...............................DAY OF ................................................ 201  .

                                 OATH/AFFIRMATION

 

 

I, ___________________________________________________ hereby declare under oath, hereby truly affirm that to the best of my knowledge and belief the aforegoing statements are true, complete and correct.

 

 

                                                                                        ___________________________

                                                                                              SIGNATURE OF DEPONENT

 

I certify that, before administering the oath/affirmation*, I asked the deponent the following questions and wrote down his/her* answers in his/her* presence:

 

1.         Do you know and understand the contents of the above declaration?

 

Answer: ___YES__________________________________________________

 

2.         Do you have any objection to taking the prescribed oath?

 

Answer: ___NO___________________________________________________

 

3.         Do you consider the prescribed oath to be binding on your conscience?

 

Answer: ___YES__________________________________________________

 

 

 

 

I certify that the deponent has acknowledged that he/she* knows and understands the contents of this declaration which was sworn to/affirmed before* me, and the deponent's signature/thumb print/mark* has placed thereon in my presence.