The dpsa - Department of Public Service and Administration



ANNEXURE A: FINANCIAL DISCLOSURE FORMFinancial Year:Personal detailsSurnameFirst NamesID NumberPersal NumberJob Title Salary LevelPostal AddressResidential AddressName of Department(National / Provincial)Cell NumberE-mail addressDetails of financial interestsShares or any other form of equity in a registered private or public company or any other corporate entity recognised by law: Number of shares/extent of equityNatureNominal valueName of company/entityLoan accounts (excluding bond, vehicle finance, and retail accounts)Name of the financial services provider and account numberOriginal amount of the loanOutstanding balanceTerm of the loanAny other financial interestsDescription of the financial interestNature of the financial interestName of the company or corporate entityAnnual value of the financial interestIncome generating assetsDescription of the assetNature of activityNature of incomeAnnual amount or value of incomeTrustsName of trust and your role Reference/registration number and the region where the trust is registeredPurpose of the trustAnnual benefits or remuneration NB: Documentary proof of approval to perform other remunerative work must be uploaded to the eDisclosure system or attached to this form if you receive remuneration for your participation as Trustee. Directorships and PartnershipsName of corporate entity Registration NumberType of Business Annual amount of RemunerationNB: Documentary proof of approval to perform other remunerative work must be uploaded to the eDisclosure system or attached to this form. Other remunerative work outside the employee’s department Name of EmployerType/nature of business activity Annual remunerationNB: Documentary proof of approval to perform other remunerative work must be uploaded to the eDisclosure system or attached to this form. Consultancy and retainershipsNature of consultancy / retainershipName of the company / your client in case of retainershipType/nature of business activity of the company/clientAnnual value of remuneration/benefits receivedNB: Documentary proof of approval to perform other remunerative work must be uploaded to the eDisclosure system or attached to this form. Sponsorships Source of assistance/ sponsorshipDescription of assistance/ sponsorshipValue of assistance/ sponsorshipRelationship between the sponsor and the departmentGifts and hospitality from a source other than a family memberDescription of a gift and/or hospitalityValue SourceRelationship between the giver and the departmentNB: If the cumulative value of the gift(s) is R350.00 proof of prior approval from the relevant authority must be uploaded to the eDisclosure system or attached to this form.Ownership and other interests in immovable propertyDescription of immovable propertyExtent / size in m? or haArea in which it is situatedPurchase price Outstanding bond on the propertyEstimated market valueVehiclesDescription (make and model of the vehicle) Registration numberPurchase priceOutstanding amount owing on the vehicleDeclarationI declare that I have personally completed this form and disclosed all relevant details required for the listed financial disclosure categories.I hereby certify that the disclosure information is true, complete and correct to the best of my knowledge.I also understand that it is binding on my conscience. _____________________________________SIGNATURE OF DESIGNATED EMPLOYEEDATE:________________________PLACE:________________________DATE SUBMITTED TO RELEVANT AUTHORITY: _______________________________________________________________________________SIGNATURE OF HEAD OF DEPARTMENT / EXECUTIVE AUTHORITY ................
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