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APPLICATION

for SOCIAL ASSISTANCE


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.