COVID-19 PROJECT SUPPORTING WINDOWS AND ORPHANS 2021

APPLICANT CASE FORM

Visiting date:
PERSONAL ID

Full name: Age:

Location: Contact:

TYPE OF CASE:

Widow _ Single mom _

No married _ Old age _

Orphan _ Poor family _

Other

How long she’s been widow? How many kids she is raising?
Widow

Is there anyone with any disability? Is there anyone helping the family?

How many kids she is caring for? Are the kids registered on their father?
Single
Mom

How long she’s been single mom? The kids receive child support?

Are the kids studying?

ECONOMY AND HOUSING SITUATION

Means of subsistence: _

Housing condition: _

Housing facilities:
Water service: _

Normal bed: _
Electricity: _
Brick stove: _
Electrical appliances:
_
Case picture

Applicability percentage: _ Also candidate to: _