Msf Financial Assistance Declaration Form printable pdf download

Msf Financial Assistance Declaration Form

Financial Assistance Declaration Form

This form is to be completed by patients/clients who are applying for financial assistance on top of the financial

subsidy/grants that they are receiving.

Complete this Declaration Form with the particulars of your Immediate Family Members (IFM)

and as per the

instructions within;

Attach clear photocopies (front and back) of:

(a) NRIC/Birth Certificate

/Special Pass of Main Applicant and

(b) NRIC/Birth Certificate

/FIN/Special Pass/Foreign Passport

of all IFMs;

IFMs listed below must have completed means-testing within the past two years and have a valid means-testing

result prior to the release of data for financial assistance; and

Submit the completed Declaration Form and all supporting documents to:

Harbourfront Centre Post Office, P.O. Box 074, Singapore 910932

I am applying for financial assistance at

(name of service provider)

Reason for financial assistance:

Name

NRIC/Birth Certificate

IC Type

Date of Birth

Relationship

(as in NRIC)

/FIN/Special Pass/

to applicant

Foreign Passport No

(Applicant)

(IFM)

Immediate family members refer to applicant’s parents, spouse and children regardless of whether they are staying with applicant

Birth certificates are only applicable for persons below age 15

Only applicable to foreigners with no special pass or other passes issued by ICA, MOM or other Government Agencies

These are Singapore Citizens, Permanent Residents, Special Pass, FIN and Foreign Passport

Apr 2014

Msf Financial Assistance Declaration Form