INDIGENT APPLICATION FORM
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Instructions:
1) This application can only completed for the person who is responsible for the payment of the Municipal account
2) Copies of municipal account, identification documents, and proof of income (where applicable) must be attached to the application form
3) Attach any other supporting documents that may be relevant for the application
4) The application form must be duly signed by the relevant Ward Councillor or any other delegated Councillor
5) Please ensure that this form is completed accurately as possible.
6) Please ensure that you receive a receipt as proof of application.
7) Applications with missing information and/or without all the relevant documentation will not be accepted.
8) The Indigent status is only valid for a period of 24 Months
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NOTE:
Submission of complete application form does not
necessarily ensure approval of registration as an Indigent person.
Payment for services provided by Council is still the
responsibility of the account holder.
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SECTION 4: INCOME
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SECTION
5: SERVICES AND SUPPORT TO HOUSEHOLD
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SECTION
6: SKILLS AUDIT
DECLARATION
I
__
__ (please print name) the undersigned,
hereby declare that the information provided
above is to the best of my knowledge true and correct and further
acknowledge that:
1.
This application for Indigent
Registration is subject to Council approval or whosoever is authorized to do
so.
2.
I acknowledge outstanding amounts
owing to the Council on account number _
_and accept that
it remains an obligation from my side.
3.
I must pay all future service
consumption rendered by the Council to me and if I fail to pay, the normal
credit control policy measures will be applicable to me.
4.
This information is public and
Public Sector includes the Provincial and National Government as well as the
Credit Bureau.
5.
I acknowledge that the Council will
install a water restriction device and/or electricity prepaid meter if approved
as Indigent.
6.
In terms of the Indigent Management
Policy, an application will be processed if supported by the following:
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a. Copy of Municipal Account
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e. Affidavit
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b. Copy of ID
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f. Copy of Death Certificate if owner is
deceased
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c. Confirmation of Pension status – if applicable
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g. Letter of Authority for Beneficiary
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d. Copy of Proof of Income
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7.
I acknowledge that I have received a confirmation of application
letter stating my application reference number.
8.
I am aware that any false
declaration will lead to my immediate disqualification from the system.
Signed at ___________________________________ on this __________ day of _________________________________
20_______.
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Signature
of Applicant
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Date
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Name
of Ward Councillor
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Signature
of Ward Councillor
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Date
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Documentation
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Copy of Identity Document
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Yes
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No
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Proof of Income/Affidavit
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Yes
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No
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Municipal Account
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Yes
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No
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FOR OFFICE USE
ONLY
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APPROVED
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DECLINED
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COMMENTS: EVALUATION/VERIFICATION BY SCREENING
COMMITTEE
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NAME
OF SCREENING COMMITTEE MEMBER
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SIGNATURE
OF SCREENING COMMITTEE MEMBER
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DATE
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SIGNATURE
OF CHAIRPERSON
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SIGNATURE
OF DEPARTMENTAL HEAD
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DATE
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DATE
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