Pay It Forward - 178-033 NPO

Office: 0812329491
Whatsapp/SMS: 0718411488
E-Mail: greg@payitforwardsouthafrica.org
Website: www.payitforwardsouthafrica.org
Facebook: https://facebook.com/payitforwardSA/info
Founder – Greg Wells-Clifton

REQUEST FOR ASSISTANCE ASSESSMENT SHEET

(Please ensure that all fields in this document are filled out)

Name: No of Adults:
Date: Name Identity Number
Region:
Referred:
If Other, specify:

Contact Number:
Alternative Number: No of Dependants:
Physical Address: Names of Adults: Age of Adult

Postal Address:

Names of Children Age of Child

Monthly Incnome: Providor of income:

R
R
R
R

Please list Employer Names (Current or previous) with details for each person earning an income
or receiving a grant. Include telephone numbers, addresses and reporting persons for each entry.
Recipient Institution Telephone Address Contact Person

Extra Notes
 Pay It Forward - 178-033 NPO
Office: 0812329491
Whatsapp/SMS: 0718411488
E-Mail: greg@payitforwardsouthafrica.org
Website: www.payitforwardsouthafrica.org
Facebook: https://facebook.com/payitforwardSA/info
Founder – Greg Wells-Clifton

Monthly Expenditure
Description Rand Value
1 R
2 R
3 R
4 R
5 R
6 R
7 R
8 R
9 R
10 R

Details initially given: As received from the person requiring assistance. (Details here should
include a history of how the applicant came to be in the position they now find themselves, and
which has led to the request for assistance:
 Pay It Forward - 178-033 NPO
Office: 0812329491
Whatsapp/SMS: 0718411488
E-Mail: greg@payitforwardsouthafrica.org
Website: www.payitforwardsouthafrica.org
Facebook: https://facebook.com/payitforwardSA/info
Founder – Greg Wells-Clifton

If the applicant is not employed, please provide reasons / details in terms of the last Employer:

Has any other Organisation been approached in this regard?

If yes, please
provide details
and the
outcome
thereof:

Note: Pay It Forward believes that despite the situation you may be in, you as the applicant deserve
to keep your dignity. Your personal information and identity will not be shared with others who are
unrelated to this matter.

It is imperative that you are honest about the contents you place in this document as it only allows
Pay It Forward to follow the correct plan of action.
 Pay It Forward - 178-033 NPO
Office: 0812329491
Whatsapp/SMS: 0718411488
E-Mail: greg@payitforwardsouthafrica.org
Website: www.payitforwardsouthafrica.org
Facebook: https://facebook.com/payitforwardSA/info
Founder – Greg Wells-Clifton

Details after Visit / Assessment - For completion by Pay It Forward

Plan of Action
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