prefix *

Mr.  Mrs.  Miss

First and last name *

Address according to house registration *

Telephone number *

Disabled person/citizen ID card number (as applied for) *

Disability type *

visual disability

Hearing or communication disability

Movement or physical disability

mental or behavioral disability

intellectual disability

learning disabilities

autism disability

Status *

Single

Married

Widowed

Divorce

separated

Other

Occupation *

Monthly income *

Reference persons who can be contacted *

Telephone number/reference person *

Status of receiving government welfare benefits *

Not receiving a living allowance for the elderly

receive disability allowance

Received financial assistance for the sustenance of AIDS patients.

Move your domicile to a new place of residence.

Intent to receive living allowance *

Receive cash in person

Receive cash by attorney

Transferred into the account in the name of the eligible person

Transfer to the attorney's account