Prevention of Organised Crime Act, 1998 (Act No. 121 of 1998)

I,

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(Name)

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(Contact address, telephone number and fax number)

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(Business/employment address, telephone number and fax number)

In my capacity as

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of

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report as follows:

a)

Particulars of the person against whom the suspicion has been formed

Full names:

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Identity/passport number:

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Nationality:

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Occupation:

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Residential address in the Republic:

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Business/employment address:

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Telephone numbers:

i) work:

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ii) home:

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b)

Particulars of the transaction or other action whereby the property concerned came into my possession (including date and place thereof)

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c)

Particulars of the property in respect of which the suspicion has been formed

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d)

Grounds on which the suspicion rests

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e)

List of documentation and other proof available in respect of the transaction or other action (paragraph (b)), and grounds (paragraph (d))

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f)

Copies of the following documentation, directly relevant to the suspicion and the grounds on which it rests, are attached:

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Signed at ........................................ this ................ day of............................................

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(Signature of person making the report)