POPIA Form 5

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:

    • Affidavits or other documentary evidence in support of the request must be attached.

    • If the space provided for in this Form is inadequate, submit information as an annexure to this form and sign
      each page.

    Mark the appropriate box with an "x"

    Complaint regarding

    PART I

    ALLEGED INTERFERENCE WITH THE PROTECTION OF THE PERSONAL INFORMATION
    (Section 74(1) of the Protection of Personal Information Act, 2013 (Act No. 4 of 2013)

    A

    PARTICULARS OF COMPLAINANT

    Surname of complainant

    Full names of complainant

    Identity number of complainant

    Residential, postal or business address

    Contact number(s)

    Fax number:

    E-mail address:

    B

    PARTICULARS OF BODY/RESPONSIBLE PARTY INTERFERING WITH PERSONAL INFORMATION

    Full names and surname of person interfering with personal information (if the person is a natural person)

    Name of public or private body (if not a natural person)

    Residential address (if applicable postal address or business address

    Contact number(s)

    Fax number:

    E-mail address

    C

    REASONS FOR COMPLAINT(Please provide detailed reasons for the complaint)

    Please write reasons for complaint

    PART II

    GRIEVANCE REGARDING DETERMINATION OF ADJUDICATOR
    (Section 74(2) of the Protection of Personal Information Act, 2013 (Act No. 4 of 2013)

    A

    PARTICULARS OF COMPLAINANT

    Surname of complainant

    Full names of complainant

    Identity number of complainant

    Residential, postal or business address

    Contact number(s)

    Fax number

    E-mail address

    B

    PARTICULARS OF ADJUDICATOR

    Full names and surname of adjudicator

    Name and surname of responsible party (if it is a public or private body)

    Residential, postal or business address

    Contact number(s)

    Fax number

    E-mail address

    C

    REASONS FOR COMPLAINT (Please provide detailed reasons for the grievance)

    Please write reasons for complaint

    _________________________________

    Signature of complainant/person aggrieved

    Contact

    JD House, 27 Stiemens Street, Braamfontein,
    Johannesburg, 2001.

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