Low-Income Medical Aid Renewal Document
Applicant Information
Full Name
Date of Birth
Address
Phone Number
Email
Household Information
Number of Household Members
List names and ages of household members
Financial Information
Source(s) of Income
Monthly Household Income
Please attach income proof documents.
Medical Coverage Information
Current Medical Aid Number
Type of Coverage Needed
Declaration
I declare that the information provided above is true and accurate to the best of my knowledge.
Applicant Signature
Date