Applicant FullName

Email Address

Contact Number

Person/Entity on Consolidated List of Targeted Financial Sanctions pursuant to section 26A of the Financial Intelligence Centre Act, 2001

Relations to person/entity

Institutions holding assets

Please enter required amount in ZAR

Food Stuffs

Rent or Mortgage

Medicine or Medical Treatment

Taxes

Insurance Premiums

Public Utility Charges

Maintenance Order

Reasonable Professional Fees

Reimbursement of expenses associated with provision of legal services

Satisfy Judgment or arbitral award

Payment to a third party due under contract

Accrue interest or other earnings due on accounts

Payment due to a person or entity affected by a prohibition

Other Expense

Other Expense Total

Total Amount Required

Obligatory Supporting Documentation to accompany this application

1. A copy of the Applicants Identity Document or Passport
2. A declaration by an affidavit declaring:
a) the applicant's interest in the property;
b) all the applicant's assets and liabilities; and
c) that the applicant cannot meet the expenses out of property not subject to section 26B.

If the applicant is a third party, the following document must accompany this application -
1. Copy of judgment, award, contract or agreement, as may be applicable