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Beneficiary Registration

Region: Gaza

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Head of household name

ID number

Phone number

Area / neighbourhood

Detailed residence address

Number of family members

#	Name	Age	Gender	Marital status

Housing type

Approximate monthly income

Is the breadwinner working?

Yes No

Job (if any)

Chronic illness or disability in the family Orphans in the family Widow / female head of household Displaced / left home

Number of orphans (if any)

Health notes (optional)

Additional notes (optional)

Have you previously received aid parcels / benefits?

Yes No

If yes, please give details (source / when)