Financial Assistance Preliminary Assessment Form

Personal:

Housing Address: Ang Mo Kio Bedok Bishan Bukit Batok Bukit Merah Bukit Panjang Bukit Timah Changi Choa Chu Kang Clementi Geylang Hougang Jurong East Jurong West Kallang Mandai Marine Parade Newton Novena Orchard Outram Pasir Ris Paya Lebar Pioneer Punggol Queenstown River Valley Rochor Seletar Sembawang Sengkang Serangoon Sungei Kadut Tampines Tanglin Toa Payoh Woodlands Yishun
Housing Type: 1-room/2-room 3-room 4-room 5-room / Executive Condo Landed Property Private Apartment & Condominiums
Latest payslip
IR8A Employee Earnings (if you are self-employed)
CPF statement/letter of employment for yourself (i.e., that of patient),
Other sources of income (e.g., rental, pension, annunity, CPF payout)
Savings: All updated bankbooks/statements (including personal/joint/fixed deposit accounts) of patient and spouse
Latest CPF statement of yourself (i.e, patient) and spouse (past 12 months transaction history)
Insurance policies of yourself (i.e, patient)

Family

Name	NRIC	Nationality	Age	Relationship to patient	Occupation	Gross Income	Nett Income

Add Row

Monthly Household Expenses:

Item	Expenses ($)	Remarks
Food	0
Utilities (electricity)	0
Housing (rental/instalment in cash)	0
Household durables (e.g., electrical appliances)	0
Conservancy	0
Public Transport	0
Private Transport (i.e, personal vehicle)	0
Communication (i.e., mobile, home internet, landline, etc.)	0
Healthcare	0
School Expenses	0
Childcare Expenses	0
Contribution to family	0
Insurance	0
Loan Instalments (e.g., hire purchase, housing, car, renovation, education, credit card, etc.)	0
Taxes/licence fees	0
Domestic Helper	0
Miscellaneous	0
Total	0