Request for access to record of private body

POPI Act: Form C

Section 1: Particulars of private body

Section 2: Particulars of the 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.

Section 3: 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.

Section 4: 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.

Section 5: Fees

(a) A request fo 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 and time required to search for and prepare a record.
(d) If you qualify for exemption of the payment of any fee, please state the reason for exemption.

Section 6: 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 below, state your disability and indicate in which form the record is required.


(a) Compliance with your request for access in the specific form may depend on the form in which the record is available.
(b) Access in the form requested may be refused in certain curcumstances. 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.

Select the appropriate box

If the record consists of visual images (videos, photographs, slides, etc)

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

If the record consists of visual images (videos, photographs, slides, etc.)

*If you requested a copy or transcription of a record (above), do you wish the copy or transcription to be posted to you? Postage is payable.

Section 7: particulars of right to be exercised or protected

Section 8: Notice of decision regarding request of 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.