행복바라미지원 대상자 지원신청서

행복바라미 지원 대상자행복바라미 지원대상자 신청서 (서식1)   ○ 추천기관 <table style="border: 0.28pt solid rgb(0, 0, 0); border-collapse: collapse;"><tbody><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 70.76pt; height: 22.29pt;" vAlign="center">추천기관</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 112.76pt; height: 22.29pt;" vAlign="center">   </td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 109.93pt; height: 22.29pt;" vAlign="center">신청(추천)금액 </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 190.94pt; height: 22.29pt;" vAlign="center"> 원 </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 70.76pt; height: 22.29pt;" vAlign="center">담당자명</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 112.76pt; height: 22.29pt;" vAlign="center">   </td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 109.93pt; height: 22.29pt;" vAlign="center">담당자연락처</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 190.94pt; height: 22.29pt;" vAlign="center">   </td></tr></tbody></table>    ○ 신청자 현황 <table style="border: 0.28pt solid rgb(0, 0, 0); border-collapse: collapse;"><tbody><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 13.8pt;" vAlign="center"> 신청 구분(해당부분 √)</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 13.8pt;" vAlign="center" colSpan="12">   ○ 소년소녀가장( ) ○ 무의탁 노인( ) ○ 빈곤노인 가장( ) ○ 무의탁 청소년( ) ○ 극빈 및 저소득 가정( ) ○ 저소득 다문화 가정( ) ○ 빈곤 이주민 가정( )   </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 26.54pt;" vAlign="center">지원 대상자명</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 83.28pt; height: 26.54pt;" vAlign="center" colSpan="2">   </td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 75.72pt; height: 26.54pt;" vAlign="center" colSpan="2">성별</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 106.3pt; height: 26.54pt;" vAlign="center" colSpan="4">   </td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 42.27pt; height: 26.54pt;" vAlign="center" colSpan="2">나이</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 96.51pt; height: 26.54pt;" vAlign="center" colSpan="2">   </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 26.54pt;" vAlign="center">주민등록번호</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 265.3pt; height: 26.54pt;" vAlign="center" colSpan="8">-</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 42.27pt; height: 26.54pt;" vAlign="center" colSpan="2">종교</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 96.51pt; height: 26.54pt;" vAlign="center" colSpan="2">   </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 37.29pt;" vAlign="center">주 소</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 212.62pt; height: 37.29pt;" vAlign="center" colSpan="6"> -   </td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 69.99pt; height: 37.29pt;" vAlign="center" colSpan="3">전화번호</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 121.47pt; height: 37.29pt;" vAlign="center" colSpan="3">Tel)H.P)</td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 30.78pt;" vAlign="center">보호구분</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 30.78pt;" vAlign="center" colSpan="12">국민기초생활수급자( ) 차상위계층( ) 그 외 저소득층( ) </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 37.29pt;" vAlign="center">세대구분</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 37.29pt;" vAlign="center" colSpan="12">한부모가정( ) 조손가정( ) 다문화가정( ) 이주민( )장애인가정( ) 무의탁, 홀몸 어르신( ) 북한이탈주민( ) 기타( )</td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 22.29pt;" vAlign="center">월평균소득</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 159pt; height: 22.29pt;" vAlign="center" colSpan="4">원</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 123.61pt; height: 22.29pt;" vAlign="center" colSpan="5">월평균 필요 최저생활비</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 121.47pt; height: 22.29pt;" vAlign="center" colSpan="3"> 원</td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 22.29pt;" vAlign="center">지원금 사용처</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 22.29pt;" vAlign="center" colSpan="12">교육비( ) 의료비( ) 생활비( ) </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 137.27pt;" vAlign="center" rowSpan="6">가족사항</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 25.12pt;" vAlign="center">관계</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 25.12pt;" vAlign="center" colSpan="2">성명</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 25.12pt;" vAlign="center" colSpan="2">주민번호(앞6자리)</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 25.12pt;" vAlign="center" colSpan="2">직업</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 25.12pt;" vAlign="center" colSpan="2">월소득</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 25.12pt;" vAlign="center" colSpan="2">동거여부</td><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 25.12pt;" vAlign="center">건강상태</td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 22.43pt;" vAlign="center">본인</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 22.43pt;" vAlign="center">   </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 22.43pt;" vAlign="center">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 22.43pt;" vAlign="center">   </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 22.43pt;" vAlign="center">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 22.43pt;" vAlign="center">   </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 22.43pt;" vAlign="center">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 22.43pt;" vAlign="center">   </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 31.31pt; height: 22.43pt;" vAlign="center">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 57.53pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 89.19pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 64.35pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 40.23pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 63pt; height: 22.43pt;" vAlign="center" colSpan="2">   </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 58.47pt; height: 22.43pt;" vAlign="center">   </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 374.27pt;" vAlign="center" rowSpan="5">생활실태 (간략히 작성)</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 118.29pt;" vAlign="center" colSpan="12">1. 건강상태         </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 75.06pt;" vAlign="center" colSpan="12">2. 경제상황       </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 66.8pt;" vAlign="center" colSpan="12">3. 주거환경 및 생활실태       </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 57.29pt;" vAlign="center" colSpan="12">4. 타 사회복지 기관의 지원 여부     </td></tr><tr><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 56.83pt;" vAlign="center" colSpan="12">5. 기타사항     </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 56.5pt;" vAlign="center">추천사유</td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 56.5pt;" vAlign="center" colSpan="12">추천기관 의견   </td></tr><tr><td style="background: rgb(216, 216, 216); padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 82.08pt; height: 27.72pt;" vAlign="center">신청자계좌번호 </td><td style="padding: 1.41pt; border: 0.28pt solid rgb(0, 0, 0); width: 404.08pt; height: 27.72pt;" vAlign="center" colSpan="12">은행명 : 계좌번호 : </td></tr></tbody></table>    ○ 첨부서류 1: 국민기초생활수급권증명서 또는 차상위계층증명서 ○ 첨부서류 2: (1)의 서류가 구비되지 않을 경우 건강보험료 납부확인서 또는 의료급여증 사본, 소득금액증명서 ○ 첨부서류 3: (해당자에 한함) 한부모가족증명서, 장애수당지급대상확인서, 장애인등록증명서 가족관계증명원, 장애인등록증명서, 외국인등록증 사본 ○ 첨부서류 4: (공통사항) 주민등록등본, 지원금을 수령할 통장 사본(수령대상자와 신청자 일치) ○ 대학생의 경우 : 한국장학재단의 국가장학금(Ⅰ유형, Ⅱ유형)에 해당하는 서류제출   2016년 월 일   신청자 (인)   상기와 같이 행복바라미 지원대상자로 추천합니다.   추천기관 :   추천자 (인)