Title *

Mr.  Mrs.  Ms.

Full Name *

Home plate address. *

Phone Number *

Disabled person/citizen identification card number (applied for) *

The type of disability. *

Visual disability

Hearing or communication disability

Movement or physical disability

Mental or behavioral disability

Intellectual disability

Learning disabilities

Autistic disability

Status *

Single

Married

Widowed

Divorced

Separated

Other

Occupation *

Monthly income *

Reference persons who can be contacted *

Telephone number/reference person *

Status of receiving government welfare benefits *

Not receiving elderly living allowance

received disability allowance

Received financial assistance to support AIDS patients.

Move to a new place of residence.

Intent to receive living allowance *

Receive cash in person

Receive cash by attorney

Transfer into the account in the name of the eligible person.

Transfer into the attorney's account.