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Republic: Polytechnic

This document is an income declaration form completed by Mr. Lim Lain Kait, who declares that he is the relative of student Lim Lian Xuan. Mr. Lim declares his monthly income is $3,500 and that he is self-employed owning his own business. He signs the form, declaring the information provided is true and understands false information could result in disciplinary action against the student.

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Lim Liang Xuan
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58 views

Republic: Polytechnic

This document is an income declaration form completed by Mr. Lim Lain Kait, who declares that he is the relative of student Lim Lian Xuan. Mr. Lim declares his monthly income is $3,500 and that he is self-employed owning his own business. He signs the form, declaring the information provided is true and understands false information could result in disciplinary action against the student.

Uploaded by

Lim Liang Xuan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC

Student ID: 20007322


Student Full Name. Lim Liang Xuan

POLYTECHNIC
Note: This form is for family members who are self-employed, unemployed and employed with odd job/irregular
income who are unable to submit latest income documents. You can use Adobe Acrobat DC to digitally fill and sign
on this form.
Annex A

FINANCIAL ASSISTANCE SCHEME APPLICATION


INCOME DECLARATION FORM

1, *Mr/Mar/Ms Lim Lain Kait


NRIC No. S1804380G

*parent/guardian/sibling/relative of Lim Lian Xuan


NRIC No. T0116825D

hereby declare that my latest total gross income is $ 3,500.00


per month

Please complete and select where applicable

D
lam self-employed as a own business
(name of occupation e.g. taxi driver, private-hire driver, own business). (Enclosed is my
2020/2021 Income Tax Assessment Statement and CPF Contribution History for most
recent 12 months). Family members who became private-hire drivers for less than 1 year are
to provide latest 12 consecutive private hire weekly statements (3 months) and most recent 12
months CPF. If you are unable to provide 12 consecutive weekly statements, please also
submit Declaration Form Annex B stating detailed reasons, in addition to available
weekly statements and recent 12 months CPF.

I am a housewife/retiree/unemployed (Enclosed is my CPF Contribution History for most


recent 12 months).

I am employed as a
(name of occupation) under Odd Job/Part-time (irregular income). (Strictly for
family members without Payslips/CPF/Employer's letter. Enclosed is my Declaration
Form Annex B with detailed reasons why my latest income documents cannot be provided).

I declare that the information provided above is true to the best of my knowledge. I understand that if the
information provided is false, the applicant's application will be rejected. The applicant is aware that if any information
provided above is subsequently found to be falsely declared, the applicant will refund the full value of the amount
awarded and will be subjected to disciplinary actions.

Signature of Family Member ....


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. . . . . . (Please do not type out name as signature. Upload image of signature if using Adobe Acrobat DC OR Sign). Date
Date 31-Mar-21
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E

FINANCIAL ASSISTANCE SCHEME APPLICATION


INCOME DECLARATION FORM

1, *M/Mdm/14s
NRIC No.

*parent/guardian/sibling/relative of Lim Lian Xuan


NRIC No. T0116825D

hereby declare that my latest total gross income is $


per month.

Please complete and select where applicable

I am self-employed as a
(name of occupation e.g. taxi driver, private-hire driver, own business). (Enclosed is my
2020/2021 Income Tax Assessment Statement and CPF Contribution History for
most recent 12 months). Family members who became private-hire drivers for less than 1
year are to provide latest 12 consecutive private hire weekly statements (3 months) and most
recent 12 months CPF. If you are unable to provide 12 consecutive weekly statements, please
also submit Declaration Form Annex B stating detailed reasons, in addition to available
weekly statements and recent 12 months CPF.

I am a housewife/retiree/unemployed (Enclosed is my CPF Contribution History for most


recent 12 months).

I am employed as a
(name of occupation) under Odd Job/Part-time (irregular income). (Strictly for family
members without Payslips/CPF/Employer's letter. Enclosed is my Declaration Form
Annex B with detailed reasons why my latest income documents cannot be provided).

I declare that the information provided above is true to the best of my knowledge. I
understand that if the information provided is false, the applicant's application will be rejected.
The applicant is aware that if any information provided above is subsequently found to be falsely
declared, the applicant will refund the full value of the amount awarded and will be subjected to
disciplinary actions.

Signature of Family Member


.. (Please do not type out name as signature. Upload image of signature if using Adobe Acrobat DC OR Sign). Date ....
t 31-Mar-21

*Please delete where applicable. Students are to use one form per family member. Please print
and use more copies for family members to declare their income, if necessary.

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