Title *
Mr. Mrs. Ms.
Full name *
As listed on the official residence registration *
Phone number *
Disability/Citizen ID card number (submitted) *
Categories of disability *
Visual impairment
Hearing impairment or communication difficulties
Physical disability or impairment
Intellectual or behavioral disability
Intellectual disability
Learning disability
Autism spectrum disorder
Status *
Single
Married
Widowed
Divorced
Separated
Other
Occupation *
Monthly income *
Individuals who can be contacted for further information. *
Phone number/Reference person *
Status of receiving government benefits *
I have not received my elderly person's allowance.
Received disability compensation.
Received financial assistance for living expenses as an AIDS patient.
Moving to a new location
Request for subsistence allowance *
Receive cash in person
Payment made in cash by the recipient.
Transfer to the account in the name of the authorized recipient.
Transfer to the designated recipient's account.
I confirm that all requirements are met. *
"I hereby certify that I meet all the requirements, and that the above statements are true and accurate. I understand that if the information and documents submitted in this application are false, I will be subject to legal action."
I consent to the use of my personal information within the computer system. *
"I consent to the provision of my personal information to the Department of Local Administration's computer system, and I consent to the verification of my information against the government's central database."
Please include the following documents:
(1) A valid government-issued photo ID card or other identification card with a photograph.
(2) Residence address
(3) Bank deposit account ledger
(4) Power of attorney document, along with identification cards for both the person granting the power and the person receiving it.
(5) Disability identification card
Attachments must not exceed 10 MB and must be either image files or PDF files.
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