Medical Assist application form

Before starting your application, please make sure you have a copy of your CAPS statement of payment handy (PDF, JPEF or PNG format), as you will need to attach this before you can submit your application.

All fields are required unless marked as optional

Applicant details

Details of the CAPS recipient

First name *

Last name *

Phone number *

Email address *

Property details for this application

Account number (optional)

Street address *

Suburb *

Postcode *

Does the applicant currently live at this property * Yes No

Applicant relation to property

What is the relation of the applicant living at this residence?

Select a status for the applicant * Property owner Family member Tenant Other

Relation to applicant *

Please specify *

Statement of payment

To qualify for the Medical Assist allowance you need to provide your CAPS statement of payment. We accept scans or photos of the original copy.

Attach your statement of payment *

Files should be in PDF, JPEG or PNG.

Declaration

By submitting this Medical Assist application I/We declare that:

I agree to the above declaration *

Applicant details

Property details for this application

Applicant relation to property

Statement of payment

Declaration

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