SASSA Affivadit For Disability Grant
SASSA Affivadit For Disability Grant
SASSA Affivadit For Disability Grant
I, the undersigned
Surname .
Full names .
Identity Number . Age
Residing at
(physical address)
Postal Code
Do hereby state under oath that I am applying for a Disability Grant. I confirm that I am not residing in an institution funded
by the state.
Marital Status (mark appropriate box with X)
Married Unmarried
Out of Customary Asiatic Deserted > 3
In community Civil Union Never Married Divorced Widow / Widower
community Union Religion months
To be completed if Married / Divorced / Widow(er)
If applicant has more than one spouse, indicate details of each spouse on the back of this form.
State reasons if applicant does not have any of the following documents for his/her (ex) spouse or partner.
ID Document Decree of Divorce Death Certificate
Reason Reason Reason
Reason Reason Reason
Sources of Income ( (mark X in applicable box)
Self Spouse Dependant N/A
Type of Income/Profits Child
Salary or wage
Profits, Withdrawals or other Benefits from a Business / Farm (owned)
Payments from a Trust or Inheritance
Payment from Property Rights
Pension or Annuity
Ex-Gratia Payments Received
Rental Income
Profits, Withdrawals, or other Benefits from a Business / Farm (rented)
Income from Assets (interest / dividends)
Income from any RSA or International Organisation
If the applicant and / or spouse have NO source of income, please indicate below how he / she currently survive
Declaration
I declare that all information furnished in this affidavit is to the best of my knowledge true and correct. I have no objection to taking the
prescribed oath and I consider the prescribed oath to be binding on my conscience.