ANNEXURE "A"
IN THE NORTH EASTERN
DIVORCE COURT
HELD AT EMPANGENI
Case no:___2012
In the matter between:
BLACK PEPPER Plaintiff
and
WHITE PEPPER
(Born SALT) Defendant
______________________________________________________________________________
REGULATION 2 OF THE MEDIATION IN CERTAIN DIVORCE MATTERS
REGULATIONS, 1990
ARRANGEMENTS REGARDING DEPENDENT AND MINOR CHILDREN
______________________________________________________________________________
1. PARTICULARS OF PLAINTIFF/APPLICANT:
1.1 Postal Address:
P O Box 1234
3900
1.2 Residential Address:
1 Pepper Place, BIRDSWOOD
1.3 Telephone Number:
035-_____________
1.4 Name & Address of Employer:
Robinsons Spices
11 Union Street
RICHARDS BAY
1.5 Telephone Number:
035-__________
1.6 Gross Monthly Income:
R10 000-00
1.7 Extent of Monthly Financial Commitments:
Water & Electricity
Lodging
Groceries
Policies
Motor vehicle instalment
Insurance
2. PARTICULARS OF DEFENDANT
2.1 Postal Address:
P O Box 124
RICHARDS BAY
3900
2.2 Residential Address:
1 Pepper Place BIRDSWOOD
RICHARDS BAY
2.3 Telephone Number:
035-____________
Pick & Pay
Boardwalk Centre
RICAHRDS BAY
2.5 Telephone Number:
Unknown
2.6 Gross Monthly Income, if known:
R5000-00
2.7 Extent of Monthly Financial Commitments, if known:
Unknown
3. GENERAL INFORMATION:
3.1 State the full name, gender and date of birth of each minor dependant child of the marriage:
BLACK PEPPER JNR, a male, 5/7/2000.
3.2 State with whom the children are living at present:
The minor child is resident with the Plaintiff and Defendant.
3.3 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:
Plaintiff at 36 Pipit Place, BIRDSWOOD, RICHARDS BAY.
3.4 State the name of the school of 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:
Chilli & pepper Primary School
1 South Street, BIRDSWOOD, RICHARDS BAY.
3.5 Is the envisaged that the children, after the conclusion of the action/application, will have to change schools? If so, give full details:
NO
3.6 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 attach recent medical reports:
N/A
3.7 State who is supporting the children at present, or contribution to their support, and to what extent:
Both parties are presently supporting the minor children.
3.8 What arrangements have been made regarding rights of contact of your husband/wife. State the details of any of such arrangements:
The parties have not agreed on primary care giving in respect of the minor child.
3.9 Set out any further details concerning your minor or dependant children which may be relevant to the custody of, access to and financial provision for such children, e.g. whether any such children have been convicted if 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).
N/A
3.10 State briefly the extent to which the above arrangements regarding your minor or dependant children are the result of mutual agreement with your husband/wife:
Primary care giving in respect of BLACK PEPPER JNR is contested.
3.11 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:
Yes, Richards Bay
DATED AT RICHARDS BAY
OATH/AFFIRMATION
I, ___________________________________________________ hereby declare under oath, hereby truly affirm that to the best of my knowledge and belief the aforegoing 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: ___YES__________________________________________________
2. Do you have any objection to taking the prescribed oath?
Answer: ___NO___________________________________________________
3. Do you consider the prescribed oath to be binding on your conscience?
Answer: ___YES__________________________________________________
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* has placed thereon in my presence.
