ANNEXURE A
FORM 1
(REGULATION 2 OF THE MEDIATION IN CERTAIN DIVORCE MATTERS REGULATIONS, 1990)
ARRANGEMENTS REGARDING DEPENDENT AND MINOR CHILDREN
CASE NO__________________200
IN THE HIGH COURT OF SOUTH AFRICA
________________________________________________________________________DIVISION
IN THE MATTER BETWEEN
________________________________________________________PLAINTIFF / APPLICANT
AND
_____________________________________________________DEFENDANT / RESPONDENT
1. PARTICULARS OF PLAINTIFF / APPLICANT
POSTAL ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
RESIDENTIAL ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
TELEPHONE NO: (HOME) _________________________________________
GROSS MONTHLY INCOME _______________________________________
EXTENT OF FINANCIAL COMMITMENTS
________________________________________________________________________
________________________________________________________________________
NAME AND ADDRESS OF EMPLOYER:
________________________________________________________________________
________________________________________________________________________
TELEPHONE NO: (WORK) _________________________________________
2. PARTICULARS OF DEFENDANT / RESPONDENT
POSTAL ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
RESIDENTIAL ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
TELEPHONE NO: (HOME) _________________________________________
GROSS MONTHLY INCOME _______________________________________
EXTENT OF FINANCIAL COMMITMENTS
________________________________________________________________________
________________________________________________________________________
NAME AND ADDRESS OF EMPLOYER:
________________________________________________________________________
________________________________________________________________________
TELEPHONE NO: (WORK) _________________________________________
3. GENERAL INFORMATION
State full name, gender and date of birth of each minor or dependent child of the marriage :
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
7. ________________________________________________________________________
8. ________________________________________________________________________
9. ________________________________________________________________________
10.________________________________________________________________________
State with whom the children are living at present:
__________________________________________________________________________________________________________________
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.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
State the name of the school or 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:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
It is envisaged that the children, after the conclusion of the action / application, will have to change schools? If so, give full details :
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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 attached recent medical reports.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
State who is supporting the children at present, or contributing to their support, and to what extent:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What arrangements have been made regarding rights of access of your husband / wife? State the details of any such arrangement:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Set out any further details concerning your minor or dependent children which may be relevant to the custody of, access to any financial provision for such children, e.g. whether any such children have been convicted of 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)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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 :
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
SIGNED AT ________________________________________ THIS __________________DAY OF ______________20_________
_____________________________________________________
SIGNED
OATH / AFFIRMATION
I, _____________________________________________________________________hereby declare under oath / hereby
truly affirm, that to the best of my knowledge and belief the foregoing 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:__________________________________________________
2. Do you have any objection to taking the prescribed oath? Answer:__________________________________________________
3. Do you consider the prescribed oath to be binding on your conscience? Answer:__________________________________________________
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 was placed thereon in my presence.
_____________________________________________________
JUSTICE OF THE PEACE / COMMISSIONER OF OATHS
_____________________________________________________
FULL NAME
_____________________________________________________
DESIGNATION (RANK) AND AREA FOR WHICH APPOINTED. BUSINESS ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
DATE: ______________________________________ |
PLACE: ________________________________________________ |