Statutory Declaration For Claims For Payment (Page 2 of 2) in pdf

Statutory Declaration For Claims For Payment Page 2

Annex D to IV.4

I, _______________________________________ [name of the claimant], Hong Kong

Identity Card/Passport*

No.: ____________________________________________ of

______________________________________________________________________

[address of the claimant], solemnly and sincerely declare that:

(a)

I departed/will depart* from Hong Kong on ________________________

[dd/mm/yyyy] to reside elsewhere with no intention of returning for employment

or to resettle in Hong Kong as a permanent resident;

(b)

I am permitted to reside in ______________________ [country for settlement];

(c)

I have not previously been paid any accrued benefits in any registered scheme on

the ground of permanent departure from Hong Kong on an earlier departure date;

and

(d)

I understand that the Authority may refer my case to the Immigration Department

to ascertain my movement in relation to the departure declared in paragraph (a)

above.

And I make this solemn declaration conscientiously believing the same to be true and by virtue

of the Oaths and Declarations Ordinance (Cap. 11).

_______________________________________

[Signature of the claimant]

Declared at ______________________________, Hong Kong this ______ day of ________.

Before me,

Signature and company chop (if applicable) of

the person administering the statutory declaration: __________________________________

Name in block letters: _____________________________

Designation: _____________________________________

* Delete whichever is not applicable

The claimant should give the passport number ONLY when he/she does NOT possess a Hong Kong Identity Card

Version 12 – February 2016

Page 2

Statutory Declaration For Claims For Payment Page 2