________________________________________________________________________________________________
(street address)
Herby declare under oath that
(a) should the application in respect of Mr. / Mrs. /Miss _________________________________________ be
approved for a bona fida visit of __________________ weeks/months, no extension of stay will be applied
for.
(b) I will be responsible for his/her maintenance whilst in South Africa and undertake to pay the South African
Government all expenses incurred or to be incurred by it for arising out of repatriation of the said person from
South Africa.
(c) I further declare that the applicant will on arrival in South Africa be in possession of a valid return or
onward ticket and that his/her passport is valid to the RSA.
______________________________________
Signature
1.
___________________________
Date
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.
i)
ii)
iii)
2. I certify that the deponent has acknowledge that he/she knows and understand the contents of the declaration
which was sworn to/afforded before me and that the deponents signature/thumb print/mark was placed therein my
presence.
_______________________________
Commissioner of oaths
Full names ______________________________________________________________________
UMNYANGO WEZASEKHAYA
LEFAPHA LA DITABA TSA LEHAE
DEPARTEMENT VAN BINNELANDSE SAKE
I _____________________________________________________________________________________
(full names and surname)
residing at _____________________________________________________________________________
(street address)
to visit me/my business in the Republic of South Africa for ______________ days to _________________
______________________________________________________________________________________
(give details as to why and to what the said person has to visit South Africa)
______________________________________________________________________________________
My relationship with the said person is ______________________________________________________
______________________________________________________________________________________
(give details of relationship and if an acquaintance, how and when it originated)
I, hereby undertake to pay the South African Government all expenses it may incur for, or arising from the
contravention of any conditions of the said persons temporary residence permit and/or the tracing,
detention and removal of the said person from South Africa.
(home)
(code)
_______________
(code)