Name-Surname*

National identification card number*

Address*

Telephone number*

Proof of life*

 If attending in person

 If authorising another person to attend on your behalf

Title*

 Mr.  Mrs.  Ms.

Full name*

National identification card number*

Age*

Address*

Telephone number*

Being a recipient of living allowance*

 Older person

 Person with disabilities

 Person living with AIDS

Intend to receive a living allowance*

 Older person

 Person with disabilities

 Person living with AIDS

Do not wish to receive a living allowance*

 Do not wish to apply for subsistence allowance, etc.

Payment receipt method*

 Receive cash in person

 Transferred into the eligible bank account. 

 Receive cash by a person authorized by the eligible person.

Bank account*

Branch*

Account number*

Account name*