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    COMPLAINT FORM

    FORM 5
    [Regulation 10]

    NOTE:

    1. This form is designed to assist the Requester or Third Party (hereinafter referred to as “the Complainant”) in
      requesting a review of a Public or Private Body’s response or non-response to a request for access to records
      under the Promotion of Access to Information Act, 2000 (Act No. 2 of 2000) (“PAIA”). Please fill out this form
      and send it to the following email address: PAIAComplaints@infoRegulator.org.za or complete online
      complaint form available at https://www.justice.gov.za/inforeg/.
    2.  PAIA gives a member of the public a right to file a complaint with the Information Regulator about any of the
      nature of complaints detailed in part F of this complaint form.
    3. It is the policy of the Information Regulator to defer investigating or to reject a complaint if the Complainant has
      not first given the public or private body (herein after referred to as “the Body”) an opportunity to respond to and
      attempt to resolve the issue. To help the Body address your concerns prior to approaching the Information
      Regulator, you are required to complete the prescribed PAIA Form 2 and submit it to the Body.
    4. A copy of this Form will be provided to the Body that is the subject of your complaint. The information you
      provide on this form, attached to this form or that you supply later, will only be used to attempt to resolve your
      dispute, unless otherwise stated herein.
    5. The Information Regulator will only accept your complaint once you confirm having complied with the
      prerequisites below.
    6. Please attach copies of the following documents, if you have them:
      a. Copy of the form to the Body requesting access to records;
      b. The Body’s response to your complaint or access request;
      c. Any other correspondence between you and the Body regarding your request;
      d. Copy of the appeal form, if your compliant relate to a public body;
      e. The Body’s response to your appeal;
      f. Any other correspondence between you and the Body regarding your appeal;
      g. Documentation authorizing you to act on behalf of another person (if applicable);
      h. Court Order or Court documents relevant to your complaint, if any.
    7. If the space provided for in this Form is inadequate, submit information as an Annexure to this Form and sign
      each page.

      CAPACITY OF PERSON/PARTY LODGING A COMPLAINT

      (Mark with an "X")

      PREREQUISITES

      Did you submit request (PAIA form) for access to record of a public/private body?

      Has 30 days lapsed from the date on which you submitted your PAIA form?

      Did you exhaust all the internal appeal procedures against a decision of the Information officer of
      a public body?

      Have you applied to Court for appropriate relief regarding this matter?

      FOR INFORMATION REGULATOR’S USE ONLY

      Received by: (Full names)

      Position

      Signature (or initials)

      Complaint accepted

      Reference Number

      Postal address

      Facsimile

      Other electronic communication (Please specify)

      PART A PERSONAL INFORMATION OF COMPLAINANT

      Full Names

      Identity Number

      Postal Address

      Street Address

      E-Mail Address

      Contact Numbers

      PART B REPRESENTATIVE INFORMATION (Complete only if you will be represented. A Power of
      Attorney
      must be attached if complainant is represented, failing which the complaint will be
      rejected)

      Full Names of Representative

      Nature of representation

      Identity Number / Registration Number

      Postal Address

      Street Address

      Street Address

      Contact Numbers

      PART C THIRD PARTY INFORMATION (Please attach letter of authorisation)

      Type of Body

      Name of Public / Private Body

      Registration Number (if any)

      Name, Surname and Title of person authorised to lodge a complaint

      Postal Address

      Street Address

      Street Address

      Contact Numbers

      PART D BODY AGAINST WHICH THE COMPLAINT IS LODGED

      Type of Body

      Name of Public / Private Body

      Registration Number (if any)

      Name, surname and title of the person you dealt with at the public or private body to try to resolve
      your complaint or request for access to information

      Postal Address

      Street Address

      Street Address

      Contact Numbers

      Reference Number given (if any)

      PART E COMPLAINT Tell us about the steps you have taken to try to resolve your complaint
      (Complaints
      should first be submitted directly to the public or private body for response and possible
      resolution)

      Date on which request for access to records submitted.

      Please specify the nature of the right(s) to be exercised or protected, if a compliant is against
      a private body.

      Have you attempted to resolve the matter with the organisation?

      If yes, when did you receive it? (Please attach the letter to this application.)

      Did you appeal against a decision of the information officer of the public body?

      If yes, when did you lodge an appeal?

      Have you applied to Court for appropriate relief regarding this matter?

      If yes, please indicate when was the matter adjudicated by the Court? Please attach Court Order,
      if there is any.

      PART F DETAILED TYPE OF ACCESS TO RECORDS (Please select one or more of the following to
      describe
      your complaint to the Information Regulator)

      Unsuccessful appeal (Section 77A(2)(a) or section 77A(3)(a) of PAIA)

      I have appealed against the decision of the public body and the appeal is unsuccessful.

      Unsuccessful application for condonation (Sections 77A(2)(b) and 75(2) of PAIA)

      I filed my appeal against the decision of the public body late and applied for condonation. The
      condonation application was dismissed.

      Refusal of a request for access (Section 77A(2)(c)(i) or 77A(2)(d)(i) or 77A(3)(b) of PAIA)

      I requested access to information held by a body and that request was refused or partially refused.

      The body requires me to pay a fee and I feel it is excessive (Sections 22 or 54 of PAIA)


      Repayment of the deposit (Section 22(4) of PAIA)

      The information officer refused to repay a deposit paid in respect of a request for access which
      refused

      Disagree with time extension (Sections 26 or 57 of PAIA)

      The body decided to extend the time limit for responding to my request, and I disagree with the
      requested time limit extension or a time extension taken to
      respond to my access request

      Form of access denied (Section 29(3) or 60(a) of PAIA)

      I requested access in a particular and reasonable form and such form of access was refused.

      Deemed refusal (Section 27 or 58 of PAIA)

      Inappropriate disclosure of a record (Mandatory grounds for refusal of access to record)

      Records (that are subject to the grounds for refusal of access) have inappropriately/unreasonably
      been disclosed.

      No adequate reasons for the refusal of access (Section 56(3)(a) of PAIA)

      My request for access is refused, and no valid or adequate reasons for the refusal, were given,
      including the provisions of this Act which were relied upon for the refusal

      Partial access to record (Section 28(2) or 59(2) of PAIA)

      Access to only a part of the requested records was granted and I believe that more of the records
      should have been disclosed.

      Fee waiver (Section 22(8) or 54(8) of PAIA)

      I am exempt from paying any fee and my request to waive the fees was refused.

      Records that cannot be found or do not exist (Section 23 or 55 of PAIA)

      The Body indicated that some or all of the requested records do not exist and I believe that more
      records do exist.

      Failure to disclose records

      The Body decided to grant me access to the requested records, but I have not received them.

      No jurisdiction (exercise or protection of any rights) (Section 50(1)(a) of PAIA)

      The Body indicated that the requested records are excluded from PAIA and I disagree.

      Frivolous or vexatious request(Section 45 of PAIA)

      The Body indicated that my request is manifestly frivolous or vexatious and I disagree.

      Other (Please explain)

      PART G EXPECTED OUTCOME How do you think the Information Regulator can assist you?
      Describe the result or outcome that you seek.

      PART H AGREEMENTS The legal basis for the following agreements is explained in the Privacy Notice on how to file your complaint document. In
      order for the Information Regulator to process your complaint, you need to check each one of the checkboxes below to show your agreement:

      I agree that the Information Regulator may use the information provided in my complaint to assist it in researching issues relating to the promotion of the right of
      access to information as well as the protection of the right to privacy in South Africa. I understand that the Information Regulator will never include my personal
      or other identifying information in any public report, and that my personal information is still protected by the Protection of Personal Information Act, 2013 (Act
      No.4 of 2013). I understand that if I do not agree, the Information Regulator will still process my complaint.

      The information in this Complaint Form is true to the best of my knowledge and belief

      I authorize the Information Regulator to collect my personal complaint information (such as the information about me in this complaint form) and use it to process
      my human rights complaint relating to the right of access to information and / or the protection of the right to privacy

      I authorise anyone (such as an employer, service provider, witness) who has information needed to process my complaint to share it with the Information Regulator. The Information Regulator can obtain this information by talking to witnesses or asking for written records. Depending on the nature of the complaint, these records could include personnel files or employer data, medical or hospital records, and financial or taxpayer information.

      If any of my contact information changes during the complaint process, it is my responsibility to inform the Information Regulator; otherwise my complaint could experience a delay or even be closed.

      _________________________________

      Signature of complainant/person aggrieved

      Contact

      JD House, 27 Stiemens Street, Braamfontein,
      Johannesburg, 2001.
      Phone: 010 023 5200
      Email: enquiries@inforegulator.org.za

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