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    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

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      Johannesburg, 2001.
      Phone: 010 023 5200
      Email: enquiries@inforegulator.org.za

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