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SASSA Affivadit For Disability Grant

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ANNEXURE I-2

AFFIDAVIT FOR A 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)

My (ex) spouse / partner’s full names & surname


ID
\

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 of my / my spouse or partner’s Assets (mark appropriate Box/es with X)


Immovable Immovable Investments, Shares, share Endowment Property rights Lump sum I / we do not
property owned / property owned / bonds, loans, capital, interest in policies after invested in order own ANY assets
held under held under outstanding assets in a maturity or cash to procure an
leasehold (not leasehold debts due to you company / in hand annuity
occupied) (occupied) institution
Applicant Spouse Applicant Spouse Applicant Spouse Applicant Spouse Applicant Spouse Applicant Spouse Applicant Spouse Applicant Spouse

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.

I certify that the deponent


has acknowledged that he /
she knows and understand
the contents of this Name of Commissioner
declaration that was sworn to Commissioner /
and affirmed before me and
that the deponent’s signature SAPS
/ thumb print was placed in
Deponent’s Signature / Signature:
my presence. Rank / Force No.
Thumb Print Commissioner of Oaths
Stamp
Date C C Y Y M M D D Place

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