REPUBLIC OF SOUTH AFRICA

FORM A

APPLICATION BY WITNESS OR PROSPECTIVE WITNESS TO BE DETAINED IN

OR PLACED UNDER PROTECTIVE CUSTODY

[Section 185A (1) of the Criminal Procedure Act, 1977 (Act 51 of 1977)]

1. I, ………………………................................................................................................................................., a)
hereby make application that -
* (i) I
* and
* (ii) …….......................................................................................................................................
..............................................................................................................................................
........................................................................................................................................... b)
my .......................................................................................................................................
..............................................................................................................................................
........................................................................................................................................... c)
be detained in or placed under protective custody seeing that I have reason to believe that
*my safety / * and * the safety of the above-mentioned * person / persons is being
threatened by .......................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
........................................................................................................................................... d)
in that ...................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
........................................................................................................................................... e)

2. I-
* (i) gave or shall give evidence on .......................................................................................... f)
at ...................................................................................................................................... g);
or
* (ii) shall possibly give evidence on ......................................................................................... f)
at ...................................................................................................................................... g);
or
* (iii) have material information at my disposal and am willing to testify in a criminal court, in the
case against ...................................................................................................................... h)
with regard to the offence of .................................................................................................

Department of Justice and Constitutional Development

FORM A - APPLICATION BY WITNESS OR PROSPECTIVE WITNESS TO BE DETAINED IN OR PLACED Page 2 of 3
UNDER PROTECTIVE CUSTODY

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
.............................................................................................................................................. i)

3. The nature of the evidence that I * may/shall give is as follows:

…………….....................................................................................................................................................
…………….....................................................................................................................................................
…………….....................................................................................................................................................
…………….....................................................................................................................................................

I, ................................................................................................................................................................ ,
hereby declare that the above-mentioned information is, to the best of my knowledge, true, complete and
correct and that I am aware of the fact that it is an offence if I willfully furnish information or make a
statement which is false or misleading.

........................................................................................
(Signature/mark/thumbprint of deponent)

4. I, ................................................................................................................................................................... ,
hereby certify that I have interpreted truly and to the best of my abilities correctly in relation to the contents
of this statement and any question put to the deponent by the member.

........................................................................................
(Signature of interpreter)

….....................................................................................
(Full name)

……................................................................................
[Designation (Rank)]

........................................................................................

........................................................................................

........................................................................................

........................................................................................

(Address of employment)

Department of Justice and Constitutional Development

FORM A - APPLICATION BY WITNESS OR PROSPECTIVE WITNESS TO BE DETAINED IN OR PLACED Page 3 of 3
UNDER PROTECTIVE CUSTODY

5. I, ................................................................................................................................................................... ,
hereby certify that before the deponent affixed * his/her mark, thumbprint or signature to this form, I read
the statement to * him/her and informed * him/her that it is an offence wilfully to furnish information or make
a statement which is false or misleading.

................................................................................
(Signature of interpreter)

...............................................................................
(Full name)

.................................................................................
[Designation (Rank)]

..................................................................................

..................................................................................

..................................................................................

..................................................................................

(Address of employment)

Remarks:

a) State name and surname of witness/prospective witness.

b) State name and surname of members of the family/household in respect of whom protective
custody is required.
c) State relationship.
d) State particulars of the person/persons who threatens/threaten the safety of the person/persons
in respect of whom protective custody is required (if known).
e) State the circumstances as a result of which protective custody is required (e.g. death threat).
f) State date of trial (if known).
g) State place of trial (if known).
h) State name of person who committed the offence (if known).
i) State offence referred to in Schedule 1 to the Criminal Procedure Act, 1977, or the offence of
bribery, extortion, defeating the ends of justice or perjury.

* Delete whichever is not applicable.

Department of Justice and Constitutional Development