Joint application form for ordinary branch union members

This form may take up to 10 minutes to complete.

JOINT APPLICATION FORM FOR ORDINARY BRANCH UNION MEMBERS

U STRETCH VOUCHERS 2016 * Send Application Form to: CIEU

U CARE BACK TO SCHOOL VOUCHERS 2016 No. 3 Bukit Pasoh Road #06-00, Singapore 089817

Closing Date: 15 July 2016 (Pls note late submission will not be accepted)

The U Stretch and U Care Back to School (BTS) Vouchers are assistance programmes of the NTUC-U Care Fund, a registered charity and Institution of a Public Character (IPC). Before applying, please read the following eligibility criteria and take note of all required supporting documents. ELIGIBILITY CRITERIA: Member must have at least 6 months of continuous paid-up union membership as of July 2016 and must not be in arrears. Members WITHOUT Dependents staying in the Same Household in Singapore -  Personal Gross Monthly Income+ must be $1,450 and below, inclusive of overtime and allowances. If your application is successful, you will receive $50* worth of U Stretch Vouchers. Members WITH Dependents staying in the Same Household in Singapore -  Total Monthly Gross Household Income+ must be $3,000 and below, inclusive of overtime and allowances; OR Per Capita Income must be $750 and below if gross household income exceeds $3,000. If applying for BTS Vouchers: Member’s child/children must be attending school in 2017 at an eligible educational institution in Singapore as follows: •  Kindergarten 1 or 2; •  Government / Government-Aided / Independent Schools (Primary or Secondary) under the Ministry of Education (MOE); •  Junior Colleges; Institute of Technical Education; Millennia Institute; Polytechnics; OR •  Special Education Schools Note: Graduating students (e. g. final year junior college students) who will not be attending schools in Year 2017 will not be eligible for the Back to School Vouchers. If your application is successful, you will receive -  $100* worth of U Stretch Vouchers -  $125* worth of BTS Vouchers for each eligible school-going child (limit of one booklet per eligible child) SUPPORTING DOCUMENTS REQUIRED If Member is Employed: -  Photocopy of recent payslip (dated year 2016) OR -  CPF Statement (showing contribution history for the past 3 months) If Member is Self-Employed or Works Part-Time: -  Notice of Assessment from IRAS (Year of Assessment 2015) OR -  CPF Statement (showing contribution history for the past 3 months). If no CPF account, a written letter from CPF board is required If Member is Unemployed -  CPF Statement (showing contribution history for the past 3 months). If no CPF account, a written letter from CPF board is required AND -  Photocopy of Spouse’s payslip or CPF Statement (showing contribution history for the past 3 months) if Member is Married If applying for BTS Vouchers: -  Photocopy of Child/Children’s Birth Certificate(s) For foreign birth certificate(s), please submit Certificate of Singapore Citizenship / Re-entry Permit AND Student Pass. Note: If member has previously submitted photocopy of his/her child/children’s birth certificates for Back to School Voucher Programme in 2012 or later, member need not submit the birth certificates again. IMPORTANT INFORMATION -  Applicant may be asked to submit other supporting documents if necessary, for verification and audit purposes. -  +Gross income is defined as all income derived from employment/business. Inclusive of overtime and allowances. -  *Subject to final donations collected -  Successful applicants will be notified of voucher collection from November 2016 onwards.

此表格需大约十分钟来填写

联合申请表格《普通分会工会会员专用》

2016年《U惠》援助券

2016年《U关怀开学了》援助券

截止日期：2016年7月15日《逾期申请，将不被受理》

以上两项计划是职总U关怀基金旗下的主要援助计划。U关怀基金是个合法的公共慈善机构 (IPC)。 在提出申请之前，请阅读下列申请条件并注意所需呈交的相关证件。 申请条件: 会员必须在截至2016年7月拥有至少连续6个月的会龄并无拖欠任何会费。 会员若没有同住在新加坡的受抚养者 -  每月个人总收入须在1,450新元+及以下，包括加班费和津贴在内。 若申请被批准, 您将可领取价值50新元*的 “U惠”援助券。 会员若有同住在新加坡的受抚养者 -  家庭每月总收入+须在3,000新元及以下，包括加班费和津贴在内；或 如果家庭总收入超过3,000新元，人均月收入须不超过750新元。 若有意申请《U关怀开学了》援助券：会员的子女必须在2017年就读于在新加坡的合格学府如列下： ·  K1或K2幼儿园； ·  教育部管辖内的政府/政府辅助/自主学校(小学或中学)； ·  初级学院、工艺教育学院、励仁高级中学、理工学院 或 ·  特殊学校。 注: 凡在2017年不再就学的应届毕业生 (如最后一年的初院生) 将无资格申请《U关怀开学了》援助券。 若申请被批准, 您将可领取 -  价值100新元*的 《U惠》援助券 -  价值125新元*的《U关怀开学了》援助券给于每名就学子女 (每个家庭的就学子女每人只限发一本)。 必须呈交的相关证件 若会员是受雇人士： -  近期（年份为2016年）的薪水单的影印本 或 -  列明过去3个月公积金缴交记录的公积金结算单 若会员是自雇人士或兼职员工： -  所得税局发出的个人所得税评估通知书（估税年份为2015年 ） 或 -  列明过去3个月公积金缴交记录的公积金结算单。若无公积金户口，必须呈交由公积金局所签发的证明书 若会员是无业者： -  列明过去3个月公积金缴交记录的公积金结算单。若无公积金户口，必须呈交由公积金局所签发的证明书 以及 -  若会员是已婚者，必须呈交配偶的薪水单或列明过去3个月公积金缴交记录的公积金结算单影印本 若申请《U关怀开学了》援助券： -  子女（们）的出生证影印本^ 凡外籍出生证，请呈交新加坡公民证书 或 入境准证和学生证。 ^若您已在2012年或后期的“开学了” 援助券的申请时呈交了子女的出生证影印本，您无须再提供。 重要讯息 -  若有需要，申请者必须提供额外的证件，以做证明和审核之用。 -  +总收入是指所有从工作或生意所赚取的收入，包括加班费和津贴在内。 -  *依据总捐款而定 -  成功申请者将从2016年11月开始获得有关领取援助券的通知。

APPLICATION OF PROGRAMME (Please tick þ the programme(s) that you wish to apply) 申请计划（请在所申请的援助券计划打勾þ）

I have read the description and eligibility criteria as stated and would like to apply for the following programme(s). 我已阅读所提列的描述和申请条件，并有意申请以下计划。 o U STRETCH VOUCHERS 2016 《U惠》援助券2016 o U STRETCH VOUCHERS 2016 AND U CARE BACK TO SCHOOL VOUCHERS 2016 《U惠》援助券2016和《U关怀开学了》援助券2016

ALL FIELDS ARE MANDATORY. PLEASE USE BLOCK LETTERS AND WRITE LEGIBLY.

LATE SUBMISSION AND INCOMPLETE APPLICATION WILL NOT BE PROCESSED.

每一栏都须填写。请用英文大写并字体明确整齐。凡延误呈交或资料不完整的申请表格将一概不被受理。

(A) PARTICULARS OF APPLICANT申请者资料 (Tick þ if applicable) (请在适当的选项打勾þ)
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证的英文姓名）
Nationality 国籍	Contact No. 联络电话 (home) 住家 (mobile) 手机
Home Address in Singapore 新加坡住址	Postal Code 邮区
Residence Type居所类型 oHDB 1 Room政府组屋一房式 oHDB 2 Room 政府组屋两房式 oHDB 3 Room政府组屋三房式 oHDB 4 Room政府组屋四房式 oHDB 5 Room 政府组屋五房式 oStudio 小型公寓 oShop house店屋 oHDB Executive/Maisonette公寓式组屋 oHUDC/EC执行共管公寓 oCondo/Private Apartment公寓/私人寓所 oTerrace/Semi-Detached/Bungalow排屋/半独立式/洋房 oHDB Rental 租赁组屋 oOthers, pls state: 其他（请注明）: _______________________________________
Marital Status婚姻状况 oSingle单身 oMarried已婚 oDivorced 离婚 oSeparated 分居 oWidowed 鳏寡	Date of Birth (dd/mm/yyyy) 出生日期
Employer’s Name 雇主
Employer’s Address 雇主地址	Postal Code邮区
Occupation职业
(B) PARTICULARS OF FAMILY MEMBERS STAYING IN THE SAME HOUSEHOLD IN SINGAPORE与申请者同住在新加坡的家庭成员Family members refer to applicant’s spouse, parents and/or children only. 家庭成员只限于申请者的配偶，父母和/或子女。
FAMILY MEMBER #1家庭成员一
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称
FAMILY MEMBER #2家庭成员二
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称
FAMILY MEMBER #3家庭成员三
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称
FAMILY MEMBER #4家庭成员四
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称
FAMILY MEMBER #5家庭成员五
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称
FAMILY MEMBER #6家庭成员六
SIN NRIC / FIN 新加坡身份证	Full Name (as in NRIC / FIN) 姓名（如同身份证）
Relationship to Applicant 与申请者的关系	Date of Birth (dd/mm/yyyy) 出生日期
Occupation 职业	Gross Monthly Income (Enter ‘0’ if no income) $ 每月总收入 (若无收入, 填写’0’)
Applying for this child to receive Back to School Vouchers? (Please tick þ if applicable) 是否为此孩子申请“开学了”援助券 (请打勾þ) o No 否 o Yes是 (If yes, pls complete school details若是，请填妥以下学府资料)
Current Education Level in 2016 2016年就读年级	Name of School in 2016 2016年就读学校名称
Next Year Education Level in 2017* 2017年就读年级*	Name of School in 2017 2017年就读学校名称

*Graduating students (e. g. final year junior college students) who will not be attending schools in Year 2017 will not be eligible for the Back to School Vouchers.

*凡在2017年不再就学的应届毕业生 (如最后一年的初院生) 将无资格申请《U关怀开学了》援助券。

Please attach a separate sheet if space is insufficient 若此表格不够使用，请另备纸张填写

(C) INCOME DECLARATION BY APPLICANT申请者申报收入
Applicant’s Personal Gross Monthly Income before CPF (includes overtime & allowances): 申请者未缴公积金前的个人每月总收入(包括加班费和津贴在内):	$	Family‘s Total Monthly Gross Household Income (including applicant): 家庭每月总收入(包括申请者):	(a) $
Note: Gross Income includes overtime & allowances. 总收入包括加班费和津贴在内。 Applicant may be asked to submit other supporting documents, if necessary, for verification and audit purposes. 若有需要，申请者必须提供额外的证件，以做证明和审核之用。	Total No. of Family Members in Household (including applicant): 总家庭成员的人数(包括申请者):	(b)
Per Capita Income - (a) divide by (b) 人均收入 -（a）除于（b） :	$
(D) DECLARATION BY APPLICANT 申请者宣誓
FORM THAT IS NOT SIGNED WILL NOT BE PROCESSED. 表格若没有签名将不被处理。 PLEASE DO NOT ALTER ANY OF THE WORDINGS IN THIS SECTION. ANY ATTEMPT TO DO SO WILL BE OF NO EFFECT. 请勿在此栏目做任何更改。凡尝试更改将被视为无效。
1.  I, the applicant, declare that I have understood and complied with the eligibility criteria stated in this application form and the particulars stated in this application are true and correct, and that I have not wilfully withheld any material fact. 本人，签署人，谨此声明我已理解并符合申请表格上列明的申请条件。本人在表格中所填写的资料均属实既正确无误，毫无刻意隐瞒之处。 2.  I have noted that I may be required to furnish other supporting documents for verification and audit purposes. 如有必要，我将提供额外的证件，以做证明和审核之用。 Collection, Use and Disclosure of Personal Data 收集，使用和披露个人资料 3.  I consent to my personal data being collected, used and retained by NTUC/Union for the purposes of: (a)  processing, administering and managing my application for U Care programmes; (b)  carrying out verification and updates of my membership status and/or information I have provided in this application form; and (c)  collecting membership fees. 我同意让全国职工总会（简称职总）或其附属工会收集,使用并保留我的个人资料，以作为以下用途： (a)  为我所申请的U关怀计划,处理一切相关事宜； (b)  为我在此申请表格所提供的资料,进行审核和更新会籍；以及 (c)  收取会员费。 4.  I consent to my personal data being disclosed by: (a)  NTUC to the Union or by the Union to NTUC for the purposes of processing, administering and managing my application for U Care programmes; and (b)  NTUC/Union to their authorised data intermediaries for the purposes of processing, administering and managing my application for U Care programmes. 我同意: (a)  让职总披露我个人资料给工会或工会披露我个人资料给职总,以让职总或工会为我所申请的U关怀计划,处理一切相关事宜；和 (b)  让职总或工会把我个人资料提供给所授权的资料中介机构,以让此机构为我所申请的U关怀计划,处理一切相关事宜。 5.  I consent to be contacted by NTUC/Union via email, text messages, fax and/or post for matters relating to my application for U Care programmes and other membership matters, as well as to obtain my opinion/feedback on such matters. 我同意让职总或工会通过电邮,简讯,传真以及邮寄的方式来跟我联系有关我所申请的U关怀计划或是其他会籍事宜,并且为此类事宜征求我的意见或反馈。 6.  For the purposes of employment-related matters, I consent to NTUC/Union obtaining my personal data and relevant data relating to my employment from my company. 为处理与雇佣相关事宜,我同意让职总或工会向我的雇主索取有关我个人和就业的相关资料。 7.  I understand the decision made by NTUC on the outcome of this application shall be final. 我理解职总将保留对此申请结果的最终决定权。 X Name of Applicant NRIC/FIN of Applicant Signature of Applicant Date 申请者姓名 申请者身份证号码 申请者签名 日期

FOR OFFICIAL USE
Administrators to note: Please scan the application form and all supporting document(s) and upload onto U Care System. Please retain this original application form until 31 Dec 2017 if a scanned copy has been uploaded onto U Care System. Otherwise, please retain for 5 years for IPC audit purposes.
Application received on:	Received application with supporting documents: o Yes o No
Application created/submitted in UCS on:	Created/Submitted by Administrator:
Outstanding supporting document(s), if any:
Remarks: