Name-Last name*

ID card number*

Address*

Telephone number*

certification of life*

 In the case of coming in person

 In the case of granting authority to others to present themselves

prefix*

 Mr.  Mrs.  Miss

First and last name*

ID card number*

Age*

Address*

Telephone number*

Being a recipient of living allowance*

 Elderly people

 Disabled person

 AIDS patients

Intend to receive a living allowance*

 Elderly people

 Disabled person

 AIDS patients

Do not wish to receive a living allowance*

 Do not wish to apply for subsistence allowance, etc.

Channels for receiving money*

 Get cash yourself

 Transferred into the eligible bank account 

 Receive cash by a person authorized by the eligible person.

bank account*

Branch*

Account number*

Account name*