Assistance Schemes Application Form · residents living in Aljunied, Pasir Ris-Punggol, Tampines...

Form AS1 (Updated 01 August 2019)

Assistance Schemes Application Form

** North East CDC

reserves the right to reject

applications with

incomplete

documentation

The North East Community Development Council (NE CDC) administers local assistance programmes to help our needy residents living in Aljunied, Pasir Ris-Punggol, Tampines GRCs, Hougang and Punggol East SMCs. As a general guide, the applicant should be Singaporean / PR with household income and per capita income should not exceed $3,000 and/or $800 respectively. The types of local assistance programmes include but not limited to:

Home Home Refurbishment and Home Improvement.

Employment & Education

Employment Assistance, Interim Job Assistance, Home Business Support, Debt Advisory, Tuition for Children, Smart Phone Workshops, Skillsfuture Advice Workshops and Professional Lessons for Persons with Special Needs.

Assistance Daily Necessities Voucher, Matched Savings Plan, Elderly Befriending Service, Home Caregiving Service, Service for Will Writing, Lasting Power of Attorney (LPA) and Advance Medical Directive (AMD).

Relief Short-Term Financial Assistance and Emergency Fund.

Transport Medical Appointment Transportation and House Moving Services.

I) Documentation Submission Checklist Please take note that for ALL schemes, the following documents are required: (Please tick when enclosed)

☐ Photocopies of NRIC of applicant and all adult household members (front & back)

☐ Photocopies of birth certificate for all children attending up to pre-university educational institutions

☐ Past 3 months’ payslips OR past 6 months’ CPF statement of applicant and all adults in the household* ☐ Latest bank statement of Applicant and all household members

*For non-salaried applicants, please attach past six months CPF contribution

Name of Scheme Eligibility

Criteria

Additional Documents

Required (If Any)

☐ Dedicated North East Ambulance (DNA)

(Subsidised transportation service for clients with difficulties in

walking) Household

Income less than

$3,000

AND/OR

Per Capita

Income less than

$800

☐ Medical Documents or

Verification from doctor of

applicant’s disabled condition

☐ Annex Form A

☐ A-Better-Home @ North East

(Basic & essential home repairs for non-rental public housing

such as electrical, sanitary/plumbing, dislodged tiles, etc. )

☐ Photos of repairs needed

☐ Annex Form B

☐ Community Employment Programme (EA)

(6-month interim employment programme for clients who are

actively looking for employment during term of

unemployment)

☐ Community Employment Programme (AA)

(1 year interim employment programme for seniors aged 62

years and above to encourage active aging; no income criteria)

☐ Annex Form C

For CDC’s Official Use Only

Date Received: Division:


☐ Moving Aid @ North East

- Moving Service that provides point to point moving only

- Moving into or out of 3-Room Flat and below within North

East District, except upgrading.

*Additional charges for packing and/or dismantling to be

borne by client Household

Income less than

$3,000

AND/OR

Per Capita

Income less than

$800

☐ Annex Form D

☐ Home Aid @ North East

(A scheme that provides indoor manual laundry rack system

for low-income residents with mobility difficulties)

☐ Annex Form E

- For applicants staying in

public housing

- Applicant & primary

caregiver(s) have mobility

difficulties or with

disabilities

☐ Growth Fund (Milk & Diaper)

(Provision of vouchers for purchase of Formula Milk & Diapers

for children 6 years old & below)

☐ Annex Form F

☐ Life Centre @ North East

- Service for Will Writing, Lasting Power of Attorney (LPA)

Form 1 and Advance Medical Directive (AMD).

Household

Income less than

$5,000

AND/OR

Per Capita

Income less than

$1,100

☐ Annex Form G


II) Applicant’s Particulars Full Name (Per NRIC): NRIC Number:

Date of Birth (DD/MM/YY):

Gender:

☐ Male ☐ Female

Marital Status:

☐ Single ☐ Married ☐ Divorced ☐ Widowed

Nationality:

☐ Singaporean

☐ Singapore PR

Race:

☐ Chinese ☐ Malay

☐ Indian ☐ Others (Please Specify):

Language(s) Spoken:

☐ English ☐ Chinese ☐ Malay

☐ Tamil ☐ Dialect (Please Specify):

Contact Number (Home): Contact Number (Mobile): E-mail Address:

Occupation & Name of Current Employer (if any): If currently unemployed, please provide duration of unemployment:

Gross Monthly Income:

Applicant’s Residential Address:

Type of Residence:

☐ Rental HDB ☐ Purchased HDB

- ☐ 1 Room ☐ 2 Room ☐ 3 Room ☐ 4 Room ☐ 5 Room

☐ Others (Please Specify): ______________________

Has Applicant applied for a North East CDC Assistance Scheme before?

☐ Yes (Please Specify): __________________________________ ☐ No


III) Applicant’s Family Particulars

Relationship

to Applicant

Name of Family

Member NRIC

Date of Birth

(DD/MM/YY) Occupation

Gross

Monthly

Income

IV) Additional Information of Applicant (please provide details)


My Signature:

Witness’ Signature:

Date: Date:

Interpreter (If Applicable): Name: NRIC No.:

Name of Witness: NRIC No.:

V) Applicant’s Declaration

ComCare:

☐ I understand that the following may be carried out, for the purposes of facilitating my application for financial or other assistance from your Agency:

a) my Personal Information1 may be used to assess my and/or my household’s eligibility for such assistance to be provided by your Agency; and

b) my Personal Information may be used to render such assistance to me and/or my household by your Agency. I give my consent to your Agency or person authorised by MSF to collect, share and use the Personal

Information only for the purposes stated above. This consent shall be governed and construed in

accordance with the laws of the Republic of Singapore.

[If assistance is rendered to the household]: c) I confirm that all the named beneficiaries on whose behalf I have applied for assistance are aware of this

application, and acknowledge that their records may be shared in the manner stated above. 1Personal Information may relate to past, present or future matters, and includes my personal data (e.g. name, NRIC no.), personal data of my family members who may have received financial assistance and/or other types of assistance to date, and any other information about me or my family that is relevant for the Agency’s evaluation of my application for financial assistance.

Self-Declaration:

☐ I declare that the information provided is true and correct. I understand the following terms and conditions: I have agreed to allow North East CDC to refer my application to the appointed vendor(s) for the rendering

of the service approved as per my application. Neither North East CDC nor the appointed vendors/volunteers/contractors are liable for any loss/injury that may result from any of the assistance scheme I receive.

Consent for Other Purposes:

☐ I consent to the use and disclosure of my personal data to the People’s Association, its affiliated organisations /

appointed vendors and/or relevant Agencies for:

The purposes of receiving further or appropriate assistance deemed necessary.

The purposes of receiving marketing messages on programmes, courses, events, services and/or products via Telephone / SMS / Email / Mail.


Annex Form A (Dedicated North East Ambulance) Details of Medical History

Is the Applicant Wheelchair Bound? ☐ Yes ☐ No

Does the Applicant have difficulty in walking? ☐ Yes ☐ No

Additional information:

Please attach Medical Documents or Verification from doctor of applicant’s disabled condition

Other Details (if any):

Details of Medical Review

Location for Pick Up:

☐ Void Deck (Of block as per address above)

☐ Home (As per address above)

Pls provide reason: _______________________________________

☐ Others (Please Specify): ___________________________________

Frequency

☐ Weekly

☐ Monthly

☐ Bi-Monthly (Once every 2

months)

☐ Quarterly (Once every 4 months)

☐ Half Yearly (Once every 6 months)

☐ Others (Please Specify):

_______________________________

Location of Medical Review:

☐ Polyclinic (Please Specify): ______________________________

☐ Hospital (Please Specify): _______________________________

☐ Others (Please Specify): ________________________________

Note:

Applicants should include all relevant medical documents or verification from doctor of medical

condition.

Pick up will be done at the void deck (of block as per address stated) unless otherwise indicated

above.

Applicant should be at pick up location on time to avoid delays to other patients.

Dialysis patients will be charged $15 per round trip payable directly to the vendor. Any other

additional costs in addition to the ambulance transport service will be payable by the applicant

directly to the vendor.

Booking of appointment should be done at least 1 week in advance.

Cancellations must be done at least 3 working days in advance.

NECDC reserves the right to terminate the ambulance transport service for applicants who cancel/no-

show repeatedly without valid reason and/or charge the full cost of the service to the applicant.


Annex Form B (A-Better-Home @ North East)

Scope of work requested

Please tick in the box of the specific repair works requested (please specify the damage and include

photos, if any):

Electrical :

Sanitary/Plumbing :

Popping/dislodged floor tiles :

Door & lock :

Rubbish chute :

Aluminium window :

Terms & Conditions /Disclaimers

1. The intention of the programme is to provide an alternative for you to have basic and essential repair

with the advice & support of Programme Volunteers/Contractors where necessary.

2. Neither North East CDC nor the Volunteers/Contractors are liable for any loss that may result from

advice or instructions concerning repairs, for consequential loss or for any other kind of loss resulting

from work performed during the service. They will also not be liable for any injury that may result from

repair works.

3. Our Volunteers and Contractors offer their services at volunteering and pro-bono basis. While they will

try their best to assist you, there is no guarantees on the effectiveness of the repair done.

4. Our Volunteers/Contractors are only to carry out very basic and essential repair and are entitled to

decline assistance and are not obliged to carry out requests outside of the programme scope.

☐ I acknowledge and agree to the above terms & conditions/disclaimers.


Annex Form C (Community Employment Programme)

Highest Education

Qualification

None PSLE and Below COC/ISC Secondary ‘N’ Levels

‘O’ Levels (with/without pass in English) NTC2 / NTC3 / Nitec

ITC / Higher Nitec / Master Nitec Diploma and above: ______________________

Highest qualification received at:

School: __________________________________________________ Country: ___________________________

Year: __________________ Specialisation (if applicable): ______________________________________

Others

Are you willing to:

Work during weekends and public Holidays?

work for long hours (e.g. 8 hours a day)?

stand for long hours (e.g. 8 hours a day)?

work in hot and humid environments (e.g. outdoors and non-air-conditioned areas)?

carry objects weighing more than 5kg?

Yes No

Yes No

Yes No

Yes No

Yes No

Please tick Yes or No for the following questions.

1. Are you currently applying for or receiving any Financial Assistance? Yes No

If yes, please provide the details below

__________________________________________________________________________________________________

2. Do you have any medical/health conditions? Yes No


__________________________________________________________________________________________________

3. Do you have any physical disabilities that might affect your ability to work? Yes No


__________________________________________________________________________________________________


Declaration: I declare that the information provided is true and correct. I understand the following terms and

conditions:

1. The Community Employment Programme is a 6 / 12 months interim* employment programme by North East

Community Development Council (NE CDC) for registered client as he/she is searching for long-term

employment*.

2. North East CDC and its appointed agencies reserve the right to decide on the placement of applicants under the

scheme.

3. North East CDC and its appointed agencies reserve the right to decide on the contract renewal upon expiry.

4. North East CDC reserves the right to refer the applicant to the respective employment agencies to assist with the

job referral assistance.

Name: ________________________________________ NRIC: ____________________________________

Signature: ____________________________________ Date: _____________________________________

*Delete where applicable

Remarks (To be filled by Interviewer):

Recommendation by Officer

CEP EA CEP AA

Remarks (If Any):

For Official Use

The application is: Approved Not approved

_________________________________________________ __________________________________________

Stamp / Signature Date


Annex Form D (Moving Aid @ North East)

Moving House

Delivering of Item(s)

No. of item(s) (Maximum 5):

Description of item(s):

Size of item(s):

If applicable, please fill up the Donor’s details below:

Name of Donor: Contact number of Donor:

Moving From Residential Address

Block: Unit: Street: Postal Code:

Type of Dwelling: Purchased/ Rental:

Moving to Residential Address

Block: Unit: Street: Postal Code:

Type of Dwelling: Purchased/ Rental:


Annex Form E (Home Aid @ North East) Details of Medical History

Does the Applicant have permanent disability/injury (more than 6 months)? ☐ Yes ☐ No


Please attach Medical Documents or Verification from doctor of applicant’s condition


Does the Primary Caregiver have a permanent disability/injury? ☐ Yes ☐ No


Please attach Medical Documents or Verification from doctor of caregiver’s condition


Assessment by Referring Agency

Reason(s) for recommendation:

Recommendation by NECDC (after house visit for successful applicants)

NECDC will assess and install rack(s) based on suitability:

Ceiling pull-down laundry rack system

Wall-mounted laundry rack (Qty: )

Portable laundry rack (Qty: )

Remarks:


Annex Form F (Growth Fund – Milk & Diapers)

Number of children 6 years & below (0 – 5 months) _____________

(6 months – 1 year) _____________

(2 – 3 years) _____________

(4 – 6 years) _____________

Applying for Formula Milk or Diaper Vouchers? ☐ Formula Milk (2 – 6 years only)

☐ Diapers (0 months – 3 years only)


Recommendation by NECDC

Vouchers worth $600 for Diapers (0 – 5 months) Qty:__________________

Vouchers worth $500 for Diapers (6 months – 1 year) Qty:__________________

Vouchers worth $400 for Formula Milk / Diapers (2 – 3 years) Qty:__________________

Vouchers worth $300 for Formula Milk (4 – 6 years) Qty:__________________

Total Quantum:

Remarks:


Annex Form G ( Life Centre @ North East) Criteria for Eligibility;

1. Singapore Citizen within North East District

2. Household Income (HHI) of less than $5,000 AND/OR Per Capita Income (PCI) of less than $1,100

3. Subsidies will be awarded in tiers, according to applicant’s Household Income AND/OR Per

Capita Income

Tier 1 HHI less than $1900

PCI less than $650

100% subsidised

Tier 2 HHI between $1901 and $3000

PCI between $651 and $800

50% co-payment of services

from applicant

Tier 3 HHI between $3001 and $5000

PCI between $801 and $1100

70% co-payment of services

from applicant

Type of Services Required (please tick)

☐ Will Writing (please tick one type below which you are applying for)

No. Clause Description ☐ SIMPLE WILL

☐ INTERMEDIATE

WILL

☐ COMPLEX WILL

1 Appointment of

Executor/Executrix 1 Up to 2 Up to 4

2 Revocation Clause To be included To be included To be included

3 Number of Beneficiaries Up to 2 Up to 4 Up to 6

4 Two Witnesses* Provided by Life Centre if

resident is unable to

nominate one

Provided by Life

Centre if resident is

unable to nominate

one

Provided by Life

Centre if resident is

unable to nominate

one

5 Guardianship Clause - 1 1

*Excluding Syariah Wills where 2M/4F witnesses to be provided by settlor.

☐ Lasting Power of Attorney Form 1

- A maximum of 3 donees comprising of 2 primary and 1 back up

☐ Advance Medical Directive

- Applicant will be informed of arrangement to consult the appointed medical doctor for this service.


BANK BALANCE & SALARY DECLARATION FORM

(If applicant is unable to provide relevant documentation)

Please check the appropriate statement and fill in the details in the blanks provided:

☐ I declare that the total bank balance for myself and/or all household members residing in the address stated

below stands at $_________________________ as at _______________ (date). I require / do not require* NE

CDC to put up a request to the Development Bank of Singapore to waive off the bank fall below fee, if

applicable.

☐ I declare that I am currently unemployed/employed*.

[If employed] I am currently working as ___________________ (occupation) at

_____________________________________ (company). I am earning a monthly gross income (before CPF

deduction) of $_________________________ as at ____________________ (date).

Reason(s) for not being able to provide the documentation:

I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that North

East Community Development Council (NE CDC) reserves the right to verify the above information in whatever means

deemed fit and necessary. I understand that NE CDC reserves the right to reject the application should the information

declared be found to be inaccurate.

Applicant’s Signature & Date

Applicant’s Name (as per NRIC)

Applicant’s NRIC

Applicant’s Address

*Delete where applicable


For Official Use Only

North East CDC Assistance Scheme Recommendation

Referrer Details (if any) Name of Referring Agency/ Division

Name of Contact Person

Contact Number

Contact Email

Means Testing for Beneficiary’s Household Gross Household Income

Total Household Members

Per Capita Income

(Income/ Household Members)

Is Applicant currently receiving SSO assistance?

If Yes, please specify:

If Applicant was rejected by SSO, please specify reason(s):

Other Remarks:

For CDC Use / Approval

Checked by: (To be completed by CDC Manager)

Name: Signature:

Designation: Date:

Amount / Description of assistance recommended:

Supported by: (To be completed by Team Leader, if applicable)

Name: Signature:

Designation: Date:

Remarks (if any):

Approved by: (To be completed by TL / SRM / DGM / GM based on approval limit)

Name: Signature:

Designation: Date:

Remarks (if any):

Assistance Schemes Application Form · residents living in Aljunied, Pasir Ris-Punggol, Tampines...

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