Indigent Application Form
Application Start
Last Name:
First Name:
Answer Date:
Identity Number:
Account No:
Comments:
Account Holder ID:
Yes
No
Upload Account Holder ID:
Latest Municipal Account:
Yes
No
Upload Latest Municipal Account:
Proof of Income:
Yes
No
Upload Proof of Income:
Affidavit of Financial Status:
Yes
No
Upload Affidavit of Financial Status:
Statement of Monthly Income:
Yes
No
Upload Statement of Monthly Income:
Section A - Particulars of Account Holder
Title:
Mr
Mrs
Miss
Dr
First Name:
Middle Name:
Surname:
Date of Birth:
Gender:
Male
Female
Other
Marital Status:
Married - ANC
Single
Divorced
Widowed
Residential Address:
Postal Address:
Cellphone:
Email Address:
Number of People Living at Address:
Section B - Stand Details
Account No:
Town Name:
Ward No:
No of Rooms:
Stand No:
No of Structures:
Owner / Tenant Details:
Owner
Tenant
Do you rent part of the property?:
No
Yes
Type of Dwelling:
Services
Electrical
Do you have Electricity on your stand?:
Yes
No
Monthly Electrical Spend:
What do you use electricity for?:
Water
Do you have water on the stand?:
Yes
No
Type of Water Access:
Sanitation
Sanitation:
Yes
No
Sanitation Type:
Section C - Financial
Monthly Household Income
Person 1
ID No 1:
Person 1 - Initials and Surname:
Person 1 - Employed:
Yes
No
Person 1 - Monthly Income:
Person 2
ID No 2:
Person 2 - Initials and Surname:
Person 2 - Employed:
Yes
No
Person 2 - Monthly Income:
Section D - Declaration
I the applicant declare that all above information is true:
Yes
No
Signature:
Attached File:
Submit Application