CivicFlow — Wrongful Arrest Intake

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Personal Details

Your information is encrypted and protected under POPIA.

Title *

SA ID Number *

Passport No. (if no ID)

First Name *

Middle Name

Surname *

Primary Phone *

Secondary Phone

Email Address *

Residential Address *

Suburb

Province *

Next of Kin

Full Name

Contact Number

Relationship

Step 1 of 5

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Facts of the Case

Describe what happened in as much detail as possible.

Facts of the Case *

Include as much detail as possible. Minimum 100 words recommended.

Physical / Psychological Injuries

Loss of Earnings & Employment

Employment Status

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Supporting Documents

Tick each document you have and upload it. All files are stored securely.

📄 ID Document — Front

📄 ID Document — Back

🧾 Bail Receipt / Slip

🏥 Medical Report / Certificate

📷 Photo Evidence (injuries, scene)

⚖️ Court Documents

📋 Discharge / Release Papers

💰 Payslip / Proof of Employment

📁 Other Supporting Documents

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Declarations & Signature

Please read and confirm each declaration before signing.

I declare that all information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing false information may result in legal consequences.

I consent to CivicFlow collecting and processing my personal information for the purpose of this intake, in accordance with the Protection of Personal Information Act (POPIA) No. 4 of 2013.

I understand that this intake form does not constitute legal advice or establish an attorney-client relationship. CivicFlow may share my information with qualified legal practitioners solely for the purpose of this matter.

Limited Authority: I hereby authorise CivicFlow to share my intake information with an assigned qualified attorney for the purpose of legal assessment only. This authority is limited to intake referral and does not constitute power of attorney or legal representation.

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Electronic Communications and Transactions Act (ECTA) — Notice In terms of the Electronic Communications and Transactions Act No. 25 of 2002, your digital signature below constitutes a valid and legally binding electronic signature equivalent to a handwritten signature. Your signature is recorded with a timestamp linked to your intake reference number.

Digital Signature *

Sign using your mouse or finger

By signing you confirm all declarations above. Valid under ECTA No. 25 of 2002.

Wrongful ArrestIntake Form

Wrongful Arrest
Intake Form