Title *

Mr.  Mrs.  Ms.

Full name *

Address in the house registration record *

Telephone number *

The number of the disabled person's/citizen's ID card (as requested). *

The type of disability. *

Visual impairment.

Hearing or communication disability

Mobility or physical disability.

Mental or behavioral disability.

Intellectual disability.

Learning disability.

Autism Spectrum Disorder.

Status *

Single

Married

Widowed

Divorced

Separated

Other

Occupation *

Monthly income *

Reference persons who can be contacted. *

Telephone number of reference person *

State welfare status. *

Do not receive elderly subsistence allowance

Receive disability allowance

Receive subsistence assistance for persons with AIDS

Recently moved into the area

Preferred method of receiving the welfare allowance *

Receive cash in person

Receive cash through an authorised representative

Transfer to the account in the name of the entitled person.

Transfer to the authorised representative’s account