FORM NO: GA-5052-001

115202017301641
Application for Social Relief of Distress as a
response to the disaster amid Covid 19

INSTRUCTIONS:
1. Type the information on the form. The form must NOT be completed by pen.
2. All fields marked with an "*" must be filled.
3. Mark the relevant box with X.
4. After completing the form with correct and complete information, click “EMAIL” to open an email page then click
“SEND” on the email page.
To qualify for this Covid 19 SRD Grant of R350 you must:
1. be a South African Citizen, Permanent Resident or Refugee registered on the Home Affairs system; and be resident
within the borders of the Republic of South Africa;
2. be above the age of 18;
3. be unemployed;
4. not be receiving any income;
5. not be receiving any social grant;
6. not be receiving any unemployment insurance benefit and do not qualify to receive unemployment insurance benefits;
7. not be receiving a stipend from the National Student Financial Aid Scheme;
8. not be receiving any other government COVID-19 response support; and
9. not be resident in a government funded or subsidised institution.
DECLARATION AND CONSENT
I confirm that I comply with the qualifying criteria as listed above.
I have read the declaration and consent as contained in Page 2 and Page 3 of this application form.
By completing this form, I provide SASSA with the consent to verify my information against any Government or Financial
institutions including SARS, UIF, NSFAS.* Yes No

APPLICANT PARTICULARS (Full Names and Surname as it appears on ID book/Smart card/Permit)

Identification
RSA ID Document Temporary ID Refugee Permit
Type:*

Citizenship:* South African Permanent Resident Refugee

Gender:* Male Female
Do you have
a disability:* Yes No

Surname:* Ndlovu

Full names:* Winners

Initials:* W
CONTACT DETAILS
Residential Address:* Mobile No:* Alternative Phone No:

Mageva village 0789309689 0790748253

Stand no 736 Yes No
Do you have a bank account:*
Giyani
Province:* Postal Code:
LIMPOPO 0826

Email
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FORM NO: GA-5052-001

DECLARATION AND CONSENT BY APPLICANT

1. I, the undersigned, (“the Applicant”) hereby apply for the social relief of distress in terms of the Regulations made
under Section 27(2) of the Disaster Management Act, 2002 (Act No. 57 of 2002): Measures to prevent and combat the
spread of COVID-19, as amended, as indicated on the application form (“the form”) and declare that:

1.1. All information, including Personal Information, supplied to SASSA is accurate and current; and I also
agree to correct and update such information when necessary;
1.2. I understand and agree that that any false or misleading declaration is punishable by law, and will justify a
denial of my application and/or revocation of my application;
1.3. I will immediately notify SASSA of any changes in my circumstances relating to this application;
1.4. The contact details provided in the said application are valid and complete and I undertake to immediately
notify SASSA of any change in my contact details;
1.5. Further, I declare that I am:
1.5.1. A South African Citizens Permanent Resident or Refugee registered on the Home Affairs database;
1.5.2. currently residing within the borders of the Republic of South Africa;
1.5.3. above the age of 18;
1.5.4. unemployed;
1.5.5. not receiving any form of income;
1.5.6. not receiving any social grant;
1.5.7. not receiving an unemployment insurance benefit and do not qualify to receive an unemployment
insurance benefit;
1.5.8. not receiving a stipend from the National Student Financial Aid Scheme and other financial aid;
1.5.9. not receiving any other government COVID-19 response support; and
1.5.10. not a resident in a government funded or subsidized institution.
2. I understand that “Personal Information” means information relating to me as an identifiable, living, natural person
and includes all information supplied to SASSA in relation to my application. I understand that when processing my
personal information, SASSA complies with the Protection of Personal Information Act, 2013 (Act No. 4 of 2013)
[“the POPI Act”) and all other applicable legislation.
3. I acknowledge that any Personal Information supplied to SASSA is provided voluntarily and that SASSA may not be
able to comply with its obligations if the correct Personal Information is not supplied.
4. I authorize and consent to SASSA processing and verifying the “Personal Information”, as provided for in the
application form and I understand that this is done in order to assess and consider my application and benefits
(“the Purposes”). Without derogating from the generality of the aforesaid, the verification shall include but not
limited to financial status, income and / or bank balance status and fraud prevention, and I acknowledge that I
understand the purposes for which it is required and for which it will be used.

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FORM NO: GA-5052-001

DECLARATION AND CONSENT BY APPLICANT

CONT.

5. I furthermore authorize and consent to the processing and verifying of my “Personal Information”, by the banking
institutions and all government institutions deemed necessary by SASSA, for the Purposes.

6. I understand that the period for which my Personal Information would be held is for as long as is needed to achieve the
Purpose or for as long as the law requires, whichever is the longest.
7. I understand that I have a right to: access the Personal Information; correct and / or delete the Personal Information;
complain to the Information Regulator and, the right to withdraw this consent. I further understand that withdrawal of
this consent will result in the cancellation of my application for or entitlement to the social relief of distress.
8. I understand that privacy is important to SASSA and that it will use reasonable efforts in order to ensure that any Personal
Information in its possession is kept confidential, stored in a secure manner and processed in terms of the POPI Act,
and any relevant and applicable legislation for the Purposes I have authorised. I consent to SASSA to, where
necessary, sharing and disclosing the Personal Information only for the Purposes.
9. By submitting my Personal Information to SASSA in any form I acknowledge that such conduct constitutes a reasonable
unconditional, specific and voluntary written consent to the processing and verification of such Personal Information by
SASSA, the banking institutions and all government institutions deemed necessary by SASSA for the Purposes
including but not limited to:
9.1. consent and authorisation to SASSA to verify my past and present bank accounts , stocks holdings and any other
financial records relevant to the application, and to do so with any financial Institution in terms of Regulation 30 of
the Social Assistance Regulations, promulgated in terms of the Social Assistance Act, 2004 (Act No. 13 of 2004);
9.2. the South African Revenue Services (SARS) may disclose, which disclosure is in terms of section 69(6)(b) of the
Tax Administration Act, 2011 (Act No. 28 of 2011) [“Tax Act”] not prohibited, my information as provided for in
section 70(4)(a) to (e) of the Tax Act to SASSA; and
9.3. Verification of my information against the information held in the various databases such as at the Department of
Home Affairs, the Department of Labour in particular with the Unemployed Insurance Fund and the Worksmans
Compensation Fund.
10. I am accordingly advised that SASSA, banking institutions and/or all government institutions deemed necessary by
SASSA for the Purposes, are aware of, and shall comply with the data subject rights provided for in any applicable
legislation, and more specifically under section 5 of the POPI Act, and shall ensure that my Personal Information is
processed for the Purpose only, and shall be protected against any conduct in violation of the Purpose.

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