1. Commissioning Parents Details Commissioning Parent 1 First Name: Second Name: ID Number: Residential Address: Contact No.: Email Address: Work/Job Title: Employer's Details: 2. Marital Status 2.1 My Marital status is: MarriedUnmarriedCivil Union / De Facto MarriageLife PartnerCustomary Marriage We have been together for: (years). We were married on: (date). We have been married for: (years). Partners details are: Commissioning Parent 2 First Name: Second Name: ID Number: Residential Address: Contact No.: Email Address: Work/Job Title: Employer's Details: 3. Domicile 3.1 I/We are South African citizens: YesNo, our nationality is:Commissioning Partner 1: Commissioning Partner 2: 3.2 I/We currently reside in South Africa: YesNo, but I/we:3.2.2.1. We are permanent residents of: ;3.2.2.2. Lived in South Africa between (date) and (date) for a total of (years); 3.2.2.3. Have been out of country for (years); 3.2.2.4. I/We left in (years); 3.2.2.5. I/We come back to South Africa regularly, our last visit was on: (date) 3.2.2.6. I/We have family in South Africa:Yes they live in No It is still and always has been our intention to come back to South Africa to live and raise our family: Yes No 4. Whose gametes (oocytes and sperm) are being used? 4.1 I/We are using the following gametes for the artificial fertilisation of my/our surrogate: 4.1.1 The sperm of: Partner; Anonymous Donor; Known Donor – we have entered into a Known Gamete Donation Agreement Yes No 4.1.2 The oocytes (eggs) of: Partner; Anonymous Donor; Known Donor – we have entered into a Known Gamete Donation Agreement Yes No 5. Medical Reason for surrogacy? 5.1 The reasons for requiring a surrogate to carry my/our child is because: 5.2 The doctor treating me is: (name of doctor); (name of fertility clinic)*NOTE – We will obtain medical reports from your treating doctor. 6. Psychologist *NOTE – We require a psychological report of both of you. This will be obtained from a psychologist who specialises in fertility related therapy. 6.1 I/We have seen a psychologist: NoYes – the details of who we have seen are: 7. Home Description *NOTE – We are required to provide the Court with a description of your home, suburb in which you live, proximity to schools, etc. 7.1 Type of house:Free standing houseFlatTown HouseSecurity Estate7.2 Our home has the following:Number of bedrooms: Number of bathroomsPool: NoYesGarden: NoYes7.3 Proximity to Schools: km to closest school7.4 Length of time that we have lived in home: 7.5 Any other pertinent information that you can provide us will be great: 8. Criminal Record: 8.1 I/We have NOT been convicted of a criminal offence; 8.2 I/We HAVE been convicted of a criminal offence. Details of offence: Date: Description: *NOTE – You will be required to provide your fingerprints for a criminal database search, to see if you have been convicted of a criminal offence within South Africa. This report will be added to the application to the High Court. 9. Guardian 9.1 Should I/We pass away prior to any child/children being born, then I/we intend nominating the below persons to be the lawful guardian of that child/ children: First Name: Surname: Identity Number: Residential Address: Contact No.: Email Address: *NOTE – we will be required to obtain confirmation from them that they are happy to act and accept the responsibility of being the guardian of any child/ children born as a result of the surrogacy. Fertility Law will provide you with a draft letter for signature by your nominated guardian. 10. Costs of procedure, application and other related costs: 10.1 I/We understand that we will be required to pay for: 10.1.1 all medical costs associated with the artificial fertilisation, surrogacy and other necessary procedures. In this regard, you will be required to take out medical aid cover for the duration of the procedure and for a period after the birth of the child/ children and until such time as the surrogate has been declared healthy. You will be required to provide us with the details of the policy; 10.1.2 all reasonable expenses/costs associated with the artificial fertilisation, surrogacy and other necessary procedures. This includes any expense that would not ordinarily have been incurred by the surrogate had it not been for the surrogacy. You will be required to provide us with the details of the policy; 10.1.3. all legal costs associated with the drafting of the necessary surrogacy agreement and subsequent court application; 10.1.4. any loss of earnings that the surrogate might suffer as a result of the artificial fertilisation procedure, surrogacy, pregnancy and birth of the child/ children. 10. Costs of procedure, application and other related costs: 11.1 Identity Book of all the parties 11.2 Passport of all the parties 11.3 Proof of Address of all the parties 11.4 Birth Certificates of the children born to the surrogate 11.5 Marriage certificate of all parties 11.6 Surrogate Mother salary slip 11.7 Surrogate husband/partner salary slip 11.8 Medical aid details (Scheme name, policy number) – surrogate 11.9 Life and disability insurance details (Scheme name, policy number) – surrogate 11.10 Life insurance details – both commissioning parents (used for maintenance of any child born) 11.11 South African Police Service Criminal Database Extract – for all the parties: Contact Details: Nevetec, 021 911 5011, Stephen Johnson, 076 629 2924, westerncape@nevetec.co.za
