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CANCELLATION REQUEST:

Please complete the enclosed pro forma affidavit (sworn statement/solemn declaration). The
following particulars are required in terms of the Broadcasting Act, No 4 of 1999, as amended:

1. The date from which you are no longer using and/or in possession of ANY television set.

2. An explanation of what has become of the TV set that was previously in your possession and
licensed in your name. Should you have sold it or donated it as a gift TV Licences requires the
particulars (name, address and ID number) of the new owner, as well as his television licence
number, if applicable. Should your television set have been stolen, please provide us with the
case number under which the theft was reported to the Police. Should your television set have
been repossessed, the name of the store and signature or store stamp is required.

3. Since many households have more than one TV, set we also require confirmation that, apart from
the set in respect of which this cancellation has been requested, you have NO other TV set in your
possession. Please confirm by providing the relevant date in the first sentence of the pro forma
affidavit. Without such confirmation your request cannot be processed.

In order to update/verify the information on our records, the SABC reserves the right to dispatch
inspectors at a reasonable time to check whether there is a television set at any premises. Should a
set be found in your possession after processing of this request you will be liable for payment of TV
licence fees as well as the applicable penalties, and the necessary steps will be taken to recover such
moneys.

Please mail or fax the information to the SABC. Once we have received the requested
documentation, the matter will receive our urgent attention. Feel free to call our Customer Service
Centre on (011) 330-9555 if you need more information. Please quote your TV licence number in any
further communication with the SABC on this matter.
AFFIDAVIT / SOLEMN DECLARATION
(PLEASE DELETE THAT WHICH IS NOT APPLICABLE)

I, _______________________________________ do hereby make oath and say / solemnly declare that:


(INITIALS & SURNAME, in CAPITALS)

1. I have not been in POSSESSION of a TV set since _______ / ________________ / ________.


(day) (month) (year)

2. The only television set in my possession was SOLD / DONATED AS A GIFT / GIVEN AWAY:
 Date of sale / donation: _________________________________________________________

 Name & address of new owner: __________________________________________________

____________________________________________________________________________

 New owner's ID No _________________________ & TV licence no _____________________


OR:
3. The only television set in my possession was STOLEN:
 Theft reported to SA Police Service at: ____________________________________________

 Case number: __________________________ Date of theft: _________________________


OR:
4. The only television set in my possession has been UNSERVICEABLE:
 Since (date): _________________________________________________________________
OR:
5. The only television set in my possession was REPOSSESSED or the deal has been CANCELLED:
 On (date): __________________________________________________________________

 Dealer or financial institution: __________________________ STORE/DEALER STAMP


(If Applicable)

_______________
(Manager Signature)

_________________________________
SIGNATURE OF LICENCE HOLDER TV LICENCE ACCOUNT NO

IDENTITY NUMBER:

Signed and sworn / solemnly affirmed before me on the date and at the
OFFICIAL STAMP
place set out below, by the deponent who indicated that he/she knows and
understands the content of this statement; has no objection to making oath (If Applicable)
or solemn affirmation, and regards such as binding on his/her conscience.

_______________________________________________________
Commissioner of Oaths (Signature)

Full name: _____________________________________________

Capacity: ______________________________________________

Place: _________________________________________________

Date: __________________________________________________

(Please retain a copy of this documentation for your files)

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