1. PERSONAL DETAILS Identity Card Number: Name: Address: Date of Birth: Date of Marriage: Telephoen Number: Mobile Number: E-Mail: AppGhSoc(PA101_101F)eV7 Surname: Status: single separated / maintains spouse separated / does not maintain spouse married Nationality: Name and Surname of applicants father: Name and Surname of applicants mother before marriage: 2. DETTAILS OF GROUND AND HOUSE RENTS Annual House Rent paid is Annual Ground rent paid in respect of residence is House / Ground rent records are withheld for a period of Confirm that the house / ground rent records are in the name of District Officers Initials
Tick () if you would like to receive an SMS notifying
social benefit payment. Tick () if you would like to receive information and news by e-mail or SMS from the Department of Social Security. widow / widower 3. CAPITAL RESOURCES AND OTHER FAMILY INCOME DETAILS Money deposited in a bank. (Quote Bank Account Numbers and other references) BANK TYPE OF ACCOUNT ACCOUNT NUMBER ACCOUNT BEARER AMOUNT RATE OF INTERST Application received at this office on: (for Office purposes) 38, Ordnance Street, Valletta VLT2000 Tel: 2590 3000 Fax: 2590 3001 e-mail: social.security@gov.mt website: www.socialsecurity.gov.mt SPIC (Social Policy Information Centre) Tel: 159 Cultivated land. (Give details about the quality of land, dimensions and land registration book number.) Pensions, benefits or privileges. (Give all details of income source/s.) Employment, business or profession. (Include National Insurance Number and details of last employment.) All property or items of value that are not mentioned above including those transferred or passed on to other persons. Property including buildings and land. (Include address, rent paid or a rent estimate, quality of land, dimensions and ground rent paid.) Livestock and Poultry. (Give details of the type of business being made.) Money kept at home by other persons 4. DETAILS OF HEAD OF HOUSEHOLD Before applying for Social Assistance the head of household worked as a The head of household terminated employment because: The head of household is totally unable to work Head of household is regstering for work as a: (i) (ii) Head of household started or restarted registering for work on Social Security benefit is not being paid because (medical certificate attached) Name and Surname Identity Card Number 5. CHILDREN WHO ARE REGISTERING FOR WORK 7. BANK ACCOUNT DETAILS (Applicable only for Unemployment Benefit) 6. DETAILS REGARDING MEMBERS OF THE FAMILY (Start with the Head of Household) Surname and Name Date of Birth Relation to Head of Household Identity Card Number Details about: a) Employment or source of income b) Registration if unemployed Gross weekly income Lm / continues on next page IBAN: Allowance is to be deposited in a Savings or Current Bank Account but not in a Loan Account. The indicated account has to be in the name of the beneficiary. Bank: Acct. No.: 8. CORROBORATION (where applicable) I declare under oath, today Name and Surname of the corroborant Relation to Head of Houseold Signature / mark of the corroborant 9. SPINSTER / BACHELOR / WIDOWS WHO ARE TAKING CARE OF ANOTHER PERSON Identity Card Number: Name: Address: Date of Birth: Surname: Status: spinster separated maintains husband separated does not maintain husband widow Details of the person being taken care of: MEDICAL CERTIFICATE ISSUED BY A SPECIALIST IN THE MENTIONED CONDITION Does the person suffer from a physical or medical condiion? NO YES The mentioned person can take care of himself / herself all the time and regularly without help NO YES Case history Name of Specialist Signature Medical Council No. Date Relation to appplicant? Is the applicant taking care regularly of this person alone? NO YES Does applicant work? NO YES Is the applicant registering for work? NO YES Details of the applicant: 11. SHORT DESCRIPTION OF CASE (To be completed by the District Manager) 10. DECLARATION I declare, that all information given is to my knowledge true, complete and correct. I understand that if the information given is false, I/we will be penalised as stipulated in the Crimal Code and can also lose the right for benfit, or part of it, as stipulated by the Social Security Act (Chap 318) I understand that as stipulated in Article 133 of the Social Security Act (Chap 318), the Director may make necessary investigations, and may ask persons and / or entities to provide information so that the benefit will be calculated and determined. I bind myself/ourselves to inform immediately any change in circumstance to the Director. If the Director is not informed within six months from change of circumstance, entitlement for the benefit or part of may be forfeited. I understand that if for some reason or another, it is found that I was/were not entitled for Social Assistance, I will have to refund all payments received. I have witnessed the Head of Household / Authorised Agent making the above declaration at this District Office of the Department of Social Security. I am satisfied that the person understood clearly the declaration he / she signed. Signature of District Officer Date Name and Surname Relation to Head of Household Signature or mark Identity Card No. Data Protection Declaration: The Department of Social Security collects all relevant personal information to provide its services to individuals who qualify for assistance, allowance or non-contributory pensions in accordance with the Social Security Act (Cap 318). The Department may verify the information submitted by you in line with article 133 (b) of the Social Security Act to ensure its accuracy in relation to the claim. Personal data may be disclosed to departments / third parties, who may also have access to your data as authorised by law. Personal information may also be exchanged with benefits institutions of other countries to combat and deter fraud, as provided for in international treaties or bilateral agreements to which Malta is a party. You will be informed in due course of the result of your claim after it has been assessed. The Department of Social Security treats your personal information in accordance with the Data Protection Act, (Cap 440) to protect your privacy. You may request in writing to access information held about you, and eventually to rectify, and where applicable to erase incorrect information, having regard to the claim for which you applied. Such request is to be addressed to: The Data Controller at the Department and appropriate action would be taken at the earliest possible time. In making such requests, kindly quote your identity card number, national insurance number, your name and address and other relevant documentation to identify your case.