Means-Test Declaration Form

Means-Test Declaration FormThis form is used for patients/clients to undergo per capita household means-testing1 for the purpose

of application for various government subsidy schemes (see descriptions below). Besides means-

testing, patients/clients will still need to meet all other eligibility criteria to qualify for any schemes.

Patients/clients do not need to complete this form if they have already been means-tested through

any of these schemes in the past two years.

1 Household means-testing is based on all family members (whether related by blood, marriage and/or legal adoption) living in the same address as the main applicant, as reflected in the NRIC. This includes parents, spouse, children, siblings, grandchildren, and children-in-law (eg. daughter-in-law/son-in-law) etc.

Community Health Assist Scheme (CHAS): Scheme was launched in 2012 so that needy Singapore Citizens can receive subsidised treatment at General Practitioners and dental clinics near their home.

Eligibility criteria:1. Aged 40 years and above OR disabled [i.e. unable to perform at least one of the six activities of daily living (ADL*)]; and2. Per capita household monthly income of $1,500 and below OR for households with no income and living in a residence with Annual Value of $13,000 and below.

* Activities of Daily Living (ADLs) are washing/bathing, feeding, toileting, transferring, dressing and mobility.

Seniors’ Mobility and Enabling Fund (SMF) for Device, Transport and Consumable subsidies: Set up in 2011 and enhanced in 2013 to better enable Singapore Citizens to age-in-place, specifically via:

Eligibility criteria for SMF Device Subsidy:1. Aged 60 years and above;2. Undergo qualified assessor’s assessment to determine the need and type of device; and 3. Per capita household monthly income of $1,800 and below OR for households with no income and living in a residence with Annual Value of $13,000 and below.

Eligibility criteria for SMF Transport Subsidy:1. Aged 55 years and above;2. Community ambulant using a wheelchair and requiring specialised transport to attend a MOH-funded Day Rehabilitation Centre, Renal Dialysis Centre or Dementia Day Care Centre;3. Per capita household monthly income of $2,600 and below OR for households with no income and living in a residence with Annual Value of $13,000 and below; and4. No other sources of concurrent subsidy for similar specialised transport services.

Eligibility criteria for SMF Consumable Subsidy:1. Aged 60 years and above;2. Receiving home-based healthcare services or under the Agency for Integrated Care (AIC)’s Singapore Programme for Integrated Care for the Elderly (SPICE) programme;3. Per capita household monthly income of $1,800 and below OR for households with no income and living in a residence with Annual Value of $13,000 and below; and4. No other sources of concurrent subsidy for similar consumables.

1Version 2 (July 2013)

2 Birth certificates are only applicable for persons below age 15.3 Only applicable to foreigners with no special pass or other passes issued by ICA, MOM or other Government Agencies.4 If there is insufficient space on the form, you can make additional copies of the form and submit it together.5 Gross monthly income refers to your basic income, overtime pay, allowances, cash awards, commissions and bonuses.

To undergo means-testing for any of the above schemes:

1. Complete this Means-Testing Form as per the instructions within;

2. Attach clear photocopies (front and back) of a) NRIC/Birth certificate2/Special Pass of Main applicant and b) NRIC/Birth certificate2/FIN/Special Pass/Foreign Passports3 of all Household Members4;

3. Declare gross monthly income5 and attach pay slips, employment letter or any income documents of the latest month for persons aged 21 and above who a) Have gross monthly income above $5,000; or b) Are foreigners (i.e. non Singapore Citizens or non Permanent Residents).

4. Main Applicant and all Household Members aged 21 and above to sign or thumbprint on page 7 for Consent/Declaration, unless they are exempted from providing consent under the conditions stated on page 8.

5. The consent clause has been made available in four languages; English, Mandarin, Malay, Tamil. Every possible effort has been made to ensure accuracy of the information translated. In the event of doubt, the English version shall take precedence over all other translated language versions of this form.

6. Submit this completed Means-Testing Form and all supporting documents to:

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

Incomplete forms lacking consent signatures/thumbprint and/or supporting documents will be sent back to the applicants for completion.

Intermediate and Long Term Care (ILTC), Eldercare and Disability Subsidies: MOH and MSF subsidies areopen only to Singapore Citizens, Permanent Residents and Special Pass holders issued by Immigration and Checkpoints Authority of Singapore (ICA) in MOH-funded Intermediate and Long Term Care (ILTC) Institutions and MSF-funded Eldercare/Disability institutions. Applicants will be assessed for their medical and/or social needs before admission.

Appeal for exceptional use of MedisaveThis will be for appeals to use Medisave and will be assessed on a case-by-case basis.

Other SG Enabled schemes (LTA Cares Fund, Special Assistance Fund, Traffic Accident Fund) LTA Cares Fund: Provides reimbursements to persons with disability for journeys made to and from home for employment or schooling purposes.Special Assistance Fund: Provides financial assistance to low-income families in purchasing assistive equipment to aid persons with disabilities in their mobility or rehabilitation. Traffic Accident Fund: Provides assistance to traffic accident individuals to purchase assistive equipment for daily living, retrofit homes to enhance accessibility, mobility and rehabilitation; or reimburse taxi and ambulance fees for transport between the home and rehabilitation centre.


Interim Disability Assistance Programme for the Elderly (IDAPE): A monthly cash payout is given to Singapore Citizens who meet the following criteria:

1. Born before 30 September 1932 OR born between 1 October 1932 and 30 September 1962 (both dates inclusive) but with pre-existing disabilities as at 30 September 2002;2. Per capita household monthly income of $2,600 and below OR for households with no income and living in a residence with Annual Value of $13,000 and below; and3. Severely disabled (i.e. unable to perform at least three out of six ADLs*).

* Activities of Daily Living (ADLs) are washing/bathing, feeding, toileting, transferring, dressing and mobility.

Section A

Please tick ✓ the schemes that you are applying for:

Particulars of Main Applicant

Name (as in NRIC)

Email

Contact Number

CHAS IDAPESMF (Device Subsidy)

SMF (Transport Subsidy)

SMF (Consumable Subsidy)

Community Hospital

Other MOH Residential ILTC

Non-Residential MOH ILTC

Peritoneal Dialysis CommunityHaemodialysis

Residential MSF services

Non Residential MSF services

Other SG Enabledschemes

Means-Testing For FA Purpose Only

Appeals for Exceptional Use of MedisaveFDW Grant

Date of Issue of NRIC/Special Pass or Birth Certificate Registration Date (DD/MM/YYYY) Date of Birth (DD/MM/YYYY)

Declared Income (Please indicate your gross monthly income if you earn an income above $5,000 or are a foreigner, and submit supporting income documents as indicated on cover page)

S$

Chinese Malay Indian

Race

Others Male Female

Gender

HDB 1 room HDB 2 room

HDB Executive Flat HDB Studio Apartment HUDC

Private Housing (including Executive Condos)

Institution (MOH/MSF licensed home)

Others (e.g. homeless, please specify):

Dwelling Type (as per address reflected in NRIC)

HDB 3 room HDB 4 room

HDB 5 room

Yes, renting from Government

Yes, renting from open market

NoIs your place of residence rented?


NRIC / Birth Certificate / Special Pass Number:

NRIC Type: Singapore Pink IC Singapore Blue IC Special Pass

Section B Particulars of Household MembersName (as in NRIC)

Email

Date of Issue of NRIC/FIN/Special Pass/Foreign Passport or Birth Certificate Registration Date (DD/MM/YYYY) Date of Birth (DD/MM/YYYY)

Contact Number Declared Income (Please indicate your gross monthly income if you earn an income above $5,000 or are a foreigner, and submit supporting income documents as indicated on cover page)

S$


Race

Others Male Female

Gender

Relationship to Main Applicant

NRIC / Birth Certificate / FIN / Special Pass / Foreign Passport Number:

Singapore Pink IC Singapore Blue IC Special PassNRIC Type: FIN Foreign Passport

Name (as in NRIC)

Email



S$


Race

Others Male Female

Gender




Household Member 1

Household Member 2


Section B Particulars of Household MembersName (as in NRIC)

Email



S$


Race

Others Male Female

Gender




Name (as in NRIC)

Email



S$


Race

Others Male Female

Gender




Household Member 3

Household Member 4


Section C

Consent/Declaration (must be completed and signed by Main Applicant and all Household Members aged 21 and above. For anyone aged 21 and above who are unable to provide consent, please provide the details below under “Consent Exemption”.)

1. We hereby declare that all the information provided by us in this form is true, correct and accurate to the best of our knowledge. We understand and acknowledge that if any of the information provided in this form by us is false or inaccurate, we will be liable to repay in full any subsidy and financial assistance granted inclusive of all administrative expenses, and may face criminal prosecution.

2. We hereby consent to allow the following:

(a) the Comptroller of Income Tax (the “Comptroller”) and the Central Provident Fund Board (“CPF Board”) to disclose to the Government and/or its appointed agent(s) (the “Requestor”): a) income information6 and b) information relating to either our CPF Accounts and/or our participation in CPF medical schemes

necessary for the purposes of means-testing or otherwise determining access by any signee or our family members to any subsidies, financial assistance or other public schemes7 to which we have applied for assistance (the "Purpose"), as and when required from time to time; and

(b) the information provided in this application to be shared with any other appointed agents of the Government for the said Purpose, as and when required from time to time.

3. We understand and acknowledge that our information will be strictly kept confidential and will be used for the said Purpose, or for policy research purposes in which we shall not be identified as specific individuals or household.

4. Our consent under paragraph 2 shall be operative and continue to remain valid until and unless revoked in writing made to the Government and/or any appointed agent.


Persetujuan / Pengisytiharan (perlu dilengkapkan dan ditandatangani oleh Pemohon Utama dan semua Ahli Seisi Rumah yang berumur 21 tahun ke atas. Untuk yang berumur 21 ke atas yang tidak berupaya untuk memberikan persetujuan, sila berikan butiran di bawah ini dalam "Pengecualian Persetujuan".)

同意／声明（主要申请者以及所有21岁及以上的家庭成员必需填妥以下相关资料并签名。任何21岁及以上的家庭成员若无

法表示同意，请在“豁免同意”的部份提供详情。）

1. 我们在此声明我们在这份表格上所提供的所有资料均属实。若有任何不正确的地方，我们明白并认知我们必需偿还所有给予

我们的津贴和经济支援，包括所有的行政费，并且可能面对法律制裁。

2. 我们在此同意以下所列：

（a）我们同意让国内税务局审计长与公积金局，将我们的：

a) 收入资料6，以及

b) 公积金户口或公积金医疗保健计划的相关资料

提供给政府机构或指定代理。这些资料将用于我或我们的家庭成员在申请任何政府津贴或援助计划7（“目的”）时所需

要进行的支付能力调查。

（b）我们也同意让其他政府法定机构，为了以上所指的“目的”而用此申请表格内的资料。

3. 我们明白并认知我们的资料将被严守保密，只用于以上目的或政策研究用途。用于后者时，个人或家庭身份将不被单独识别。

4. 我们在上述第二段所提出的同意将起效，并持续保持有效，除非和直到以书信方式向政府以及/或任何指定代理表示撤除。

6 Income information provided by IRAS refers to Employment and/or Trade income as assessed by IRAS. Income information provided by CPF Board includes but is not limited to that which CPF Board receives from third parties. For salaried employees, 'income information' refers to the monthly income declared/derived based on the contributions submitted by employers for the 12-month period preceding the date of request for information. For self- employed persons, 'income information' refers to either: (a) the monthly income derived from the last available net trade income as assessed by the IRAS within the last 2 assessment years; or (b) the income declared to the CPF Board or the income assumed under the CPF laws within the last 2 years.7 This includes any schemes offered by the Government and Statutory Boards

6 国内税务局所提供的收入资料是国内税务局所评估的工资以及/或经商收益。公积金局所提供的收入资料包括，但不限于，第三方所支付的金额。受雇人士的‘收

入资料’指的是每月所申报/计算出的月资。此数额是按照雇主在申请日的前12个月所缴交的数额计算。自雇人士的‘收资资料’指的是以下任何一项：

(a) 国内税务局在近两年内由所评估的最后一次经商收益所取得的月资；或

(b) 近两年向公积金局申报的收入或是在公积金法令下被承认的收入。7 包括政府或法定机构下的任何计划。

Consent/Declaration 同意／声明 Persetujuan/Pengisytiharan


1. Dengan ini, kami mengisytiharkan bahawa semua maklumat yang kami di dalam borang ini adalah benar, betul dan tepat mengikut pengetahuan kami. Kami faham dan akui bahawa jika maklumat yang kami berikan di dalam borang ini adalah palsu atau tidak tepat, kami akan di pertanggungjawabkan untuk membayar balik subsidi penuh dan bantuan kewangan yang diberikan termasuk semua perbelanjaan pentadbiran, dan mungkin menghadapi dakwaan jenayah.

2. Dengan ini kami bersetuju untuk membenarkan perkara-perkara berikut;

(a) Pengawal Cukai Pendapatan ("Pengawal") dan Lembaga Tabung Simpanan Pekerja ("Lembaga CPF") untuk mendedahkan kepada Pemerintah dan / atau ejen-ejen yang dilantik ("Peminta"): a) keterangan pendapatan6 dan b) keterangan yang berkaitan dengan akaun CPF kami atau penyertaan kami dalam skim perubatan CPF

Bagi tujuan ujian kemampuan atau penentuan oleh mana-mana penanda tangan atau ahli keluarga kami untuk sebarang subsidi, bantuan kewangan atau skim-skim awam7 yang lain. Ini termasuk skim-skim lain yang ditawarkan oleh Pemerintah dan Lembaga Berkanun yang telah kami mohon untuk bantuan ("Tujuan"), apabila dikehendaki dari masa ke semasa;

(b) Maklumat yang diberikan dalam permohonan ini akan dikongsi dengan mana-mana agen yang dilantik oleh Pemerintah untuk tujuan tersebut, apabila dikehendaki dari masa ke semasa.

3. Kami faham dan akui bahawa maklumat kami akan dirahsiakan dan akan digunakan untuk Tujuan tersebut, atau untuk tujuan penyelidikan polisi di mana kami tidak boleh dikenalpasti sebagai individu atau ahli keluarga tertentu.

4. Persetujuan kami di bawah perenggan 2 akan berkuat kuasa dan terus kekal kesahihannya melainkan ia dibatalkan secara bertulis kepada Pemerintah dan / atau ejen yang dilantik.

Name of main applicant 主要申请人姓名 NRIC No. 身份证号码 Signature/Thumbprint 签名／指印Nama pemohon utama No. kad pengenalan Tandatangan/Cap jari

1.

(b)

3.

4.

2. ;

(a)

a)b)

6

7

6 Matlumat pendapatan yang disediakan oleh IRAS merujuk kepada Pekerjaan dan / atau Pendapatan Perdagangan seperti yang dinilai oleh IRAS. Maklumat pendapatan yang disediakan oleh Lembaga CPF diambil kira akan tetapi tidak terhad kepada butiran yang diterima oleh Lembaga CPF dari pihak ketiga. Untuk pekerja bergaji, 'maklumat pendapatan' merujuk kepada pendapatan bulanan yang diumumkan / diperolehi berdasarkan dari sumbangan yang diserahkan oleh majikan bagi tempoh 12 bulan sebelum tarikh permintaan maklumat. Bagi orang yang bekerja sendiri, 'maklumat pendapatan' merujuk kepada sama ada: (a) pendapatan bulanan yang diperolehi daripada pendapatan perdagangan bersih terakhir yang dinilai oleh IRAS dalam tempoh 2 tahun penilaian terakhir; atau, (b) pendapatan yang diisytiharkan kepada Lembaga CPF atau pendapatan yang diandaikan di bawah undang-undang CPF dalam tempoh 2 tahun yang lepas.7 Ini termasuk semua skim yang ditawarkan oleh Pemerintah dan Lembaga Berkanun

6

7

Name of household member家庭成员姓名 Nama ahli keluarga

NRIC No. 身份证号码No. kad pengenalan

Signature/Thumbprint 签名／指印Tandatangan/Cap jari

Date 日期 Tarikh :

/





/ / /

/









The following person (aged 21 and above) is unable to give consent.

Consent Exemption

Name (as in NRIC)


Reason: Mentally and/or physically incapacitated, where person is unable to sign or thumbprint (please fill in Doctor’s certification below)

Permanently mentally and/or physically incapacitated, where person is unable to signor thumbprint (please fill in Doctor’s certification below)

In prison

Overseas

Others (please specify):

Doctor’s certification: I certify that the above is mentally and/or physically incapacitated and is unable to provide consent for the purpose of this application.8

Name of doctor: MCR No. Signature of doctor:

Date (must be within 6 months from Contact Number:means-test date, unless permanentlyincapacitated):

Official stamp of clinic/hospital:

8 If the doctor is not present to sign and endorse on this Means-Test Declaration Form, a separate doctor’s memo indicating that the Main Applicant/Household Member is unable to give consent due to the relevant medical reason can be attached.

For use by service providers

The Declaration Form is checked by:

Name of Institution:

Name of Contact Person in the Institution:

Contact Number:

Email:

For Official Use

The Declaration Form is verified / processed by:


Means-Test Declaration Form

Documents

Transcript of Means-Test Declaration Form