Chernovetskyi Charity Fund

Questionnaire

1
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10
1

Fill in the first and last name and the age of the person / family who needs help (in the case of a family, list the names of all family members and their age) *

2

Name of the person seeking help

3

Specify:

4

Indicate availability of social status*

5

Indicate if there are people in the family who need medical care or treatment *

6

Describe in detail the nature of the assistance needed for the person/family * *

7

Describe the living conditions of the family*

8

Specify the estimated monthly income of the family *

9

Do you receive:

social allowance from the state

assistance from other Funds

10

Do people in need for assistance agree for creation and publication of photo and video materials in social networks and the mass media *