Pfa Complaint Form (Page 4 of 4) in pdf

Pfa Complaint Form Page 4

C. THE DESIRED OUTCOME/RELIEF SOUGHT

In addition to the above, kindly TICK the relevant box:

1. Have you instituted legal (court) proceedings in this matter? Yes

- If “Yes”, in which Court (name): _______________ Case no._____________

2. Has this complaint been sent to any other Ombud?

Yes

If “Yes”, which Ombud (name): ________________ Ref: _____________

By lodging this complaint form you agree to the following:

You wish the OPFA to investigate your complaint on your behalf;

Information submitted by you to this Office will be used solely for the purpose

of investigating and adjudicating your complaint;

We will at all times respect your privacy and keep your personal information

confidential;

You give consent to this Office to forward any information submitted by you to

the office with the correct jurisdiction, if the complaint does not fall within this

office’s mandate;

Where your complaint does fall under this Office’s jurisdiction that this office

may share information submitted by you with any of the relevant parties

involved in the complaint to find out important information about your case –

this consent will also include details of minor children (if applicable), i.e. birth

certificates of minors or any similar document, where they are beneficiaries

with regards to death benefit claims;

You have the right to object to the sharing of your personal information with

other parties. Should this be the case, then this Office will not be able to

investigate your complaint and your file may be closed.

_________________________

______________________

DATE

SIGNATURE

Pfa Complaint Form Page 4