I, the undersigned
(Full name and surname)
do hereby declare the following under oath:
1.
I am an adult female/male with ID --- residing at (address)with contact number ---, employed by (company name) at (address) with contact number ---
2.
(In the following paragraphs you mustcover the following information please. Tell it like a story. Please delete these questions in your affidavit they are merely there to direct your attention to the information which is required to be contained in the affidavit. If you have any pictures of the effects of the health impacts, if any , associated with the odour events and you consent to them being used please attach them to the affidavit and make sure you and the commissioner of oaths initials them. Please describe who / what is depicted in the photos, who took the photo, verify that they accurately depict what you are describing appears in the photo and the date on which it was taken.)
When you usually experience the smell;
Where do you usually experience the smell (home/ work – location). What address is this.
Are you able to state the associated wind direction (only to be included if you have verified the wind direction, if not then simply leave out this item).
Describe the smell in as much detail as possible;
Specific dates & timesif you kept a record, or state if you have reported via the UHA complaint app / website in which event you can say you have reported and not have to detail the dates and times again. Or if you have not reported every time, include the dates and times of odour events.
Any health effects? Please provide details(including if those impacts are psychological eg, anxiousness, concern for children and possible effects).Do you have any doctors notes? If so please attach.
How long in particular after the smell starts do you or your family experience any health impacts?
Were you suffering at the time from any illness which could account for the health effects other than the odour impact?
Why do you say the smell is offensive (kindly elaborate in as much detail as possible).
If you know the source, also state how you know this? Explain in detail.
Have you submitted complaints regarding the matter? Over what period. If you have logged complaints via the UHA app or website then you may say so in answer to this question just specify the period over which you logged complaints.
……………………………………………………………….
(Signature of the deponent)
I HEREBY CERTIFY that the deponent has acknowledged that he/she knows and understands the contents of this affidavit that he does not have any objection to taking the oath, and that he/she considers it to be binding on his conscience which was sworn to and signed before me at ______on this the ______day of ______2017, and that the administering oath complied with the regulations contained in Government Gazette Notice No.1258 dated 21st July 1972 (as amended).
______
COMMISSIONER OF OATHS
FULL NAMES:
ADDRESS:
CAPACITY:
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