ANNEXURE B: PRESCRIBED FORM C

REQUEST FOR ACCESS TO RECORDS HELD BY VODACOM

(Section 53(1) of the Promotion of Access to Information Act, 2 of 2000)

A. Particulars of Vodacom

The Head of Vodacom

082 Vodacom Boulevard

Vodacom Valley

Midrand

1685

or

Private bag x 9904

Sandton

2146

Telephone number: 087 289 6450 / 087 289 3501

Email: [email protected]

B. Particulars of person requesting access to the record

a) The particulars of the person who requests access to the record must be given below
b) The address and/or fax number in the Republic to which the information is to be sent must be
given
c) Proof of the capacity in which the request is made, if applicable, must be attached

Full names and surname: _________________________________________________________________

Identity number: _________________________________________________________________

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 Postal address: __________________________________________________________________

Fax number: __________________________________________________________________

Telephone number: __________________________________________________________________

E-mail address: __________________________________________________________________

Capacity in which request is made, when made on behalf of another person:

C. Particulars of person on whose behalf request is made

This section must be completed ONLY if a request for information is made on behalf of another person

Full names and surname: ____________________________________________________________

Identity number / Company Registration Number: __________________________________________

D. Particulars of record

a) Provide full particulars of the record to which access is requested, including the reference number
if that is known to you, to enable the record to be located.
b) If the provided space is inadequate, please continue on a separate page and attach it to this form.
The Requester must sign all the additional pages

1) Description of record or relevant part of the record:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________

2. Reference number, if available: ___________________________________________________

3. Any further particulars of record: __________________________________________________

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 ______________________________________________________________________________

E. Fees

a) A request for access to a record, other than a record containing personal information about
yourself, will be processed only after a request fee has been paid
b) You will be notified of the amount required to be paid as the request fee
c) The fee payable for access to a record depends on the form in which access is required and the
reasonable time required to search for and prepare such record
d) If you qualify for exemption of the payment of any fee, please state the reason for exemption.

Reason for exemption from payment of fees:

_________________________________________________________________________________

F. Form of access to record

If you are prevented by a disability to read, view or listen to the record in the form of access provided for
in 1 to 4 hereunder, state your disability and indicate in which form the record is required.

Disability: Form in which record is required:

Mark the appropriate box with an X.

NOTES:

(a) Compliance with your request in the specified form may depend on the form in which the record
is available.

(b) Access in the form requested may be refused in certain circumstances. In such a case you will be
informed if access will be granted in another form.

(c) The fee payable for access to the record, if any, will be determined partly by the form in which
access is requested.

1. If the record is in written or printed form:

copy of record* inspection of record

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 2. If record consists of visual images

(this includes photographs, slides, video recordings, computer-generated images, sketches, etc.):

view the images copy of the images* transcription of the

images*

3. If record consists of recorded words or information which can be reproduced in sound:

listen to the soundtrack transcription of soundtrack*

(audio cassette)
(written or printed document)

4. If record is held on computer or in an electronic or machine-readable form:

printed copy of record* printed copy of copy in computer

information derived from readable form*
the record*
(memory stick or compact
disc)

*If you requested a copy or transcription of a record (above), do you wish the YES NO
copy or transcription to be posted to you?

Postage is payable.

G. Particulars of right to be exercised or protected

If the provided space is inadequate, please continue on a separate page and attach it to this form. The
Requester must sign all the additional pages

1. Indicate which right is to be exercised or protected:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

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 _______________________________________________________________________________________

2. Explain why the record requested is required for the exercise or protection of the aforementioned
right:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

H. Notice of decision regarding request for access

You will be notified in writing whether your request has been approved/ denied. If you wish to be informed
in another manner, please specify the manner and provide the necessary particulars to enable compliance
with your request.

How would you prefer to be informed of the decision regarding your request for access to the record?

_______________________________________________________________________________________
_____________________________________________________________________________

Signed at this day of 20

______________________________________

SIGNATURE OF REQUESTER / PERSON

ON WHOSE BEHALF THE REQUEST IS MADE

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 AFFIDAVIT

I, the undersigned ……………………………………………………………………………. (Please insert full names) do hereby

make oath and say:

1.

I am an adult male/female residing at ……………………………………………………….. I am the requestor in terms of

the Promotion of Access to Information Act, No 2 of 2000.

2.

The facts herein contained are true and correct and within my personal knowledge, unless indicated to the

contrary, and are in all respects true correct.

3.

I am the (please select one of the options):

(a) sole owner and sole user of Vodacom Prepaid / Contract Account
(b) owner of Vodacom Prepaid / Contract Account. The sim card is not is my possession nor under my
control
(c) user of Vodacom Prepaid / Contract Account. The sim card is in my possession and under my control

I am duly authorised to lodge this request in terms of the Promotion of Access to Information Act, No 2 of

2000.

4.
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 The information requested pertains to call data (details of incoming and outgoing calls and SMSs – including

base station (tower) information (excluding the physical MSISDN of the incoming caller party) and the IMEI

number (handset information)] on a cellular number ________________ for the period _________________

and __________________ (Please also include time frames).

5.

My Identity number is ………………………………………………………… and I attach hereby a certified copy of my

identity document.

6.

I am the owner and/or authorised user of a Vodacom cellular telephone with cellular telephone number

______________________ allocated to me and I am duly authorised to consent to a third party requesting

information on my behalf in terms of the Promotion of Access to Information Act 2 of 2000.

7.

I hereby confirm that I have given consent to _____________________________ to request and receive

information (which is more fully detailed in the document attached hereto and marked Annexure _____

which has been initialled by me for purpose of identification and which is in the prescribed 6 hours allowed

by Vodacom) from Vodacom LEA Support requested on my behalf in terms of the Promotion of Access to

Information Act 2 of 2000. Furthermore, I hereby waive any rights that I may have against Vodacom in regard

to any damages that I may suffer arising from the release by Vodacom LEA Support to

____________________________________ in the information referred to in Annexure _______

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 8.

I am aware that I could be prosecuted for making a statement knowing it might be used in court proceedings

and known by me to be false and intended to mislead.

I know and understand the contents of this statement. I have no objections in taking the prescribed oath. I

consider the prescribed oath to be binding on my conscience.

SIGNED AT ___________________________ ON THIS _______________ DAY OF__________________

20____

______________________________

Deponent (Signature of person

swearing or affirming the statement)

I certify that the deponent has acknowledged that he/she knows and understands the contents of this

affidavit which was signed and sworn to, before me at this ___________ day of ____________ 20___ and

that he/she has no objection to taking the prescribed oath.

_____________________________________
SIGNATURE Commissioner of Oaths or other
official before whom the statement is
sworn/affirmed)

______________________________________
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 Full First Names and Surname

______________________________________

______________________________________

______________________________________

______________________________________
Business Address (Street Address)

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Title: Annexure B: Prescribed Form C Page 9 of 9
(In accordance with section 51 of the Promotion of Access to Information Act No. 2 of 2000)

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