Community Care Fund

One-off Allowance for New Arrivals from Low-income Families

Application Form

Reference No. (for Community Care Fund Secretariat use only) One-off Allowance for New Arrivals from Low-income Families (the Programme) Application Form Notes: 1. Please complete this Form in BLOCK letters using black or blue pen. 2. Please fill in the attached mailing labels. 3. Applicants should submit copies of the supporting documents listed in paragraph 2(g) of the Notes to Applicants at Appendix 1 together with this Form for the Programme. Part 1 Personal Particulars of Applicant

Name in Chinese (if applicable) Name in English

Surname (in Chinese)

Given Name (in Chinese)

Surname (in English) Given Name (in English)

Date of Birth Hong Kong Identity Card (HKIC) No.

dd

mm

yy

Date of Issue:

dd

mm

yy

Supporting document One-way Permit for settlement in Hong Kong Dependant visa/entry permit (Please put a in the Please state the English name of sponsor of the application for dependant visa/entry permit: appropriate box if applicable)
Surname (in English)

Given Name (in English)

Hong Kong Permanent Identity Card/ HKIC No. of sponsor Local Residential Address

# HK / Kln / NT (# Delete as appropriate)

E-mail Address (if any) Local Contact Telephone No. Part 2 Disbursement of Allowance Applicants may collect the allowance through direct payment into bank account or collect an order cheque (Please put a in the appropriate box): Direct payment into bank account (The applicant must provide the information of his/her local Hong Kong dollar sole-name savings/current account below. Please ensure that the account number provided is correct, otherwise the allowance cannot be paid into the account specified.) Name of Bank

Account No. Order cheque (Applicants shall collect the cheque in person at the Community Care Fund Secretariat during the specified period and time. Please refer to paragraph 4(c) of the Notes to Applicants for details.) Application Form Page 1 of 4

Community Care Fund

Note: If the applicant or family member residing with the applicant has not passed the means-test of the specified assistance schemes, this Part is not applicable please move on to Part 4. * I/ My family member residing with me (see Note 1) has passed the family/household-based means-test of any of the following assistance schemes at the time of submitting the application under the Programme: (* Delete as appropriate) (Please put a in the appropriate box. If more than one of the means-tests of the following schemes have been passed, the applicant only needs to put a in the box of the scheme chosen and provide a copy of the supporting document for that scheme.) [1] Comprehensive Social Security Assistance Scheme [2] Student financial assistance schemes under the Student Financial Assistance Agency (a) Tertiary Student Finance Scheme - Publicly-funded Programmes (b) Financial Assistance Scheme for Post-secondary Students (c) Financial Assistance for Primary and Secondary Students (i.e. the School Textbook Assistance Scheme, Student Travel Subsidy Scheme, Subsidy Scheme for Internet Access Charges, Examination Fee Remission Scheme, Project Yi Jin (full fee reimbursement) or Financial Assistance Scheme for Designated Evening Adult Education Courses (full/half fee reimbursement)) (d) Kindergarten and Child Care Centre Fee Remission Scheme [3] Hospital Authority Medical Fee Waiving Mechanism (excluding one-off waiver) Part 3 Specified Assistance Schemes If the applicant is not the person who applied for the scheme above, please provide as follows information of the family member who has passed the means-test concerned, and enclose a copy of documentary proof for the relationship of the family member with the applicant (e.g. marriage certificate or birth certificate, etc.): Name in Chinese
(if applicable)
Surname (in Chinese) Surname (in English) Given Name (in English) Given Name (in Chinese)

Name in English

Relationship with the Applicant Part 4 Written Declaration

parent

son/daughter

spouse (please put a in the appropriate box)

Note: If the applicant has completed Part 3, this Part is not applicable.

Warning: Any person, who knowingly or wilfully makes any false statement or withholds any information or otherwise misleads the Community Care Fund (CCF) Secretariat for the purpose of obtaining allowance under the Programme, is liable to prosecution. The deliberate provision of false information or omission of information in order to obtain allowance under the Programme by deception is a criminal offence. In addition to the consequence of being ineligible for the allowance under the Programme, the person may be liable to prosecution and on conviction to imprisonment for a maximum of 14 years under the Theft Ordinance (Cap. 210). If Part 3 is not applicable, the applicant has to declare that his/her average monthly household income in the past 3 months (see Note 2) is below the specified income limit (see paragraph 1(a)(iii)(2) of the Notes to Applicants) as follows: 1. 2. I, the undersigned, declare that I am the holder of Hong Kong Identity Card number as given in Part 1 of this Form. I hereby declare that: (i) I and family members residing with me (see Note 1) add up to _________ persons; (ii) The average monthly household income made by me and family members residing with me (see Note 1) in the past 3 months is HK$ _________________ , which is below the specified income limit applicable to my household size (including me and family members residing with me) (see paragraph 1(a)(iii)(2) of the Notes to Applicants). I understand that if I knowingly or wilfully make any false statement or withhold any information or otherwise mislead the CCF Secretariat, for the purpose of obtaining allowance under the Programme, it will render me liable to prosecution. I understand that the deliberate provision of false information or omission of information in order to obtain allowance under the Programme by deception is a criminal offence. In addition to the consequence of being ineligible for the allowance under the Programme, I may be liable to prosecution and on conviction to imprisonment for a maximum of 14 years under the Theft Ordinance (Cap. 210). Date:

3.

Signature of Applicant:

Note 1: Refers to father, mother, son, daughter, husband or wife residing with the applicant in Hong Kong (including legally recognised adoptive parents/children and illegitimate children with proof of parentage). Note 2: The average monthly household income in the past 3 months refers to the average monthly household income (i.e. the average of the total monthly income of the applicant and family members residing with the applicant in Hong Kong (see Note 1)) of the 3 months prior to the submission of application, including earnings from employment and other income (i.e. including salary, double pay/leave pay, job allowance, bonus/commission/tips, fees for rendering services, profits from business/investment, alimony, contribution from relatives/friends, interests from fixed deposits, stock and shares, etc., rental income, monthly pension/ widows and childrens compensation). Employees mandatory contribution to a Mandatory Provident Fund Scheme, payment under Governments Scheme $6,000, financial assistance provided by the Government, charitable donations and financial assistance from other assistance programmes of the CCF, etc. of the applicant and family members residing with the applicant in Hong Kong are however not included.

Community Care Fund

Application Form Page 2 of 4

Part 5

Declaration and Undertaking by Applicant

(To be completed by Applicant)

1. 2. 3.

I, the undersigned, declare that I am the holder of Hong Kong Identity Card number as given in Part 1 of this Form. I have read/have been read the Notes to Applicants at Appendix 1 and the Personal Information Collection Statement at Appendix 2(A) of this Form and I fully understand their content. I hereby authorise and consent to the Community Care Fund (CCF) Secretariat (including its agents/contractors), committees under the CCF and the relevant bureaux and departments of the Hong Kong Special Administrative Region Government (the Government) using my data, including my personal data in their possession, information provided by me in this Form and other information I have submitted/ may submit under the Programme, to process my application (including ascertaining my eligibility under the Programme) and receipt of payment under the Programme and for any purpose directly related to such purposes. Such bureaux/departments include, but are not limited to, the Home Affairs Bureau, the Immigration Department, the Correctional Services Department and other relevant government offices involved in the administration and operation of the Programme. I consent to the use of my data for any checking and/or investigation relating to my application and receipt of payment under the Programme to be carried out by the CCF Secretariat (including its agents/contractors), committees under the CCF and the relevant bureaux and departments of the Government (mentioned in paragraph 3 above), and that they may disclose the data to any other parties if the disclosure is necessary for such checking and/or investigation. I consent to the matching of my data by the CCF Secretariat with my personal data held by the Immigration Department and/or the Correctional Services Department and/or other bureaux/departments of the Government and/or their agents/contractors in relation to my application and receipt of payment under the Programme, and understand that the matching procedure is conducted for ascertaining whether I am eligible under the Programme or not and therefore I will not receive payment under the Programme in case I am ineligible. I understand and agree that the CCF Secretariat has the right to conduct comprehensive checking in the course of processing of application or after the disbursement of allowance to verify that the information submitted by me is true, complete and accurate. I and/or family members residing with me will fully cooperate with the CCF Secretariat, including the provision to the CCF Secretariat of my/our detailed income information and any other information for checking. The CCF Secretariat otherwise has the right to disqualify my application and/or request my full repayment of allowance. I confirm that I have secured the consent of family members residing with me and other relevant persons that their personal data have been or will be (as necessary) submitted to the CCF Secretariat for processing my application (including ascertaining my eligibility under the Programme) and any directly related purposes, for any checking and/or investigation relating to my application and receipt of payment under the Programme, and that the CCF Secretariat may disclose the data to any other parties if the disclosure is necessary for such checking and/or investigation. I agree that the allowance under the Programme be paid directly into my bank account as specified in this Form or that order cheque be arranged for me by the CCF Secretariat. I agree and undertake to notify the CCF Secretariat forthwith of any overpayment or any payment by mistake to me under the Programme and refund the amount as certified by the CCF Secretariat as overpayment or payment by mistake. I declare that all information provided in this Form and other information submitted/to be submitted under the Programme is true and correct. I understand that if I knowingly or wilfully make any false statement or withhold any information or otherwise mislead the CCF Secretariat, for the purpose of obtaining allowance under the Programme, it will render me liable to prosecution. I understand that the deliberate provision of false information or omission of information in order to obtain allowance under the Programme by deception is a criminal offence. In addition to the consequence of being ineligible for the allowance under the Programme, I may be liable to prosecution and on conviction to imprisonment for a maximum of 14 years under the Theft Ordinance (Cap. 210).

4.

5.

6.

7.

8.

9.

Signature of Applicant:

Date:

Community Care Fund

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Part 6

Declaration and Undertaking by Sponsor

(If the Applicant is not staying in Hong Kong legally as dependant, this Part is not applicable.)

1. 2. 3.

I, the undersigned, declare that I am the holder of Hong Kong Permanent Identity Card/Hong Kong Identity Card number of the sponsor as given in Part 1 of this Form. I have read/have been read the Notes to Applicants at Appendix 1 and the Personal Information Collection Statement at Appendix 2(B) of this Form and I fully understand their content. I hereby authorise and consent to the Community Care Fund (CCF) Secretariat (including its agents/contractors), committees under the CCF and the relevant bureaux/departments of the Hong Kong Special Administrative Region Government (the Government) using my data, including my personal data in their possession and other information I have submitted/ may submit under the Programme, to process the applicants application (including ascertaining the applicants eligibility under the Programme) and receipt of payment under the Programme and for any purpose directly related to such purposes. Such bureaux/departments include, but are not limited to, the Home Affairs Bureau, the Immigration Department and other relevant government offices involved in the administration and operation of the Programme. I consent to the use of my data for any checking and/or investigation relating to the applicants application and receipt of payment under the Programme to be carried out by the CCF Secretariat (including its agents/contractors), committees under the CCF and the relevant bureaux and departments of the Government (mentioned in paragraph 3 above), and that they may disclose the data to any other parties if the disclosure is necessary for such checking and/or investigation. I declare that my information provided in this Form and other information relating to me submitted/to be submitted under the Programme is true and correct. I understand that if I knowingly or wilfully make any false statement or withhold any information or otherwise mislead the CCF Secretariat, for the purpose of helping the applicant secure allowance under the Programme, it will render me liable to prosecution. I understand that the deliberate provision of false information or omission of information with a view to helping the applicant secure allowance under the Programme by deception is a criminal offence. In addition to the consequence of rendering the applicant ineligible for the allowance under the Programme, I may be liable to prosecution and on conviction to imprisonment for a maximum of 14 years under the Theft Ordinance (Cap. 210).

4.

5.

Signature of Sponsor:

Date:

Community Care Fund

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Appendix 1 Notes to Applicants

1. Eligibility Criteria : (a) Applicants shall meet all the following criteria: who have reached the age of 18 on or before 31 March 2012 as evidenced by their Hong Kong Identity Cards (HKIC); (ii) HKIC holders who have entered Hong Kong for settlement for less than 7 years as at 31 March 2012; and (1) have entered Hong Kong from the Mainland on One-way Permit; (2) have the right to land or on unconditional stay in Hong Kong; or (3) stay in Hong Kong legally as dependants (and their sponsors are Hong Kong permanent residents, or non-permanent residents with the right to land or on unconditional stay in Hong Kong); and (iii) from low-income families: (1) the applicant or family member residing with the applicant (see Note 1) has passed the family/household-based means-test establishing eligibility for assistance under specified assistance schemes (i.e. Comprehensive Social Security Assistance (CSSA) Scheme; or student financial assistance schemes under the Student Financial Assistance Agency (SFAA) (see Note 3); or Hospital Authority Medical Fee Waiving Mechanism (excluding one-off waiver)); or (2) with an average monthly household income in the past 3 months (see Note 2) below the following specified income limit applicable to the relevant household size: Household Size (persons) 1 2 3 4 5 6 or above Income Limit ($) 7,300 14,600 20,000 24,500 33,600 37,300 (i)

Note 1: Note 2:

Refers to father, mother, son, daughter, husband or wife residing with the applicant in Hong Kong (including legally recognised adoptive parents/children and illegitimate children with proof of parentage). The average monthly household income in the past 3 months refers to the average monthly household income (i.e. the average of the total monthly income of the applicant and family members residing with the applicant in Hong Kong (see Note 1)) of the 3 months prior to the submission of application, including earnings from employment and other income (i.e. including salary, double pay/leave pay, job allowance, bonus/commission/tips, fees for rendering services, profits from business/investment, alimony, contribution from relatives/friends, interests from fixed deposits, stock and shares, etc., rental income, monthly pension/ widows and childrens compensation). Employees mandatory contribution to a Mandatory Provident Fund Scheme, payment under Governments Scheme $6,000, financial assistance provided by the Government, charitable donations and financial assistance from other assistance programmes of the CCF, etc. of the applicant and family members residing with the applicant in Hong Kong are however not included. Supporting Documents to be Submitted Specified Assistance Schemes (must be valid at the date of submission of application form) [1] CSSA Scheme Certificate of Comprehensive Social Security Assistance Recipients (for Medical Waivers) [2] Student financial assistance schemes under the SFAA (i) Tertiary Student Finance Scheme - Notification of Result 2011/12 Publicly-funded Programmes (ii) Financial Assistance Scheme for Post-secondary Notification of Result 2011/12 Students (iii) Financial Assistance for Primary and Secondary Notification of Result (Eligibility Assessment of Students (i.e. the School Textbook Assistance Primary and Secondary Students)/ Eligibility Certificate Scheme, Student Travel Subsidy Scheme, (Financial Assistance for Primary and Secondary Subsidy Scheme for Internet Access Charges, Students) 2011/12 Examination Fee Remission Scheme, Project Yi Jin (full fee reimbursement) or Financial Assistance Scheme for Designated Evening Adult Education Courses (full/half fee reimbursement)) (iv) Kindergarten and Child Care Centre Fee Notification of Result 2011/12 Remission Scheme [3] Hospital Authority Medical Fee Waiving Mechanism Hospital Authoritys Certificate for Waiver of Medical (i.e. Waiving Mechanism for Public Hospitals and Charges Clinics) (excluding one-off waiver)

Note 3:

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(b) Those who belong to the following categories are not eligible under the Programme: (i) persons admitted into Hong Kong under the Capital Investment Entrant Scheme and their dependants; (ii) persons admitted into Hong Kong under the Quality Migrant Admission Scheme and their dependants; (iii) persons admitted into Hong Kong for employment as imported workers under the Supplementary Labour Scheme; (iv) persons admitted into Hong Kong under the Working Holiday Scheme; (v) foreign domestic helpers; (vi) visitors; (vii) persons admitted under the following immigration policies/arrangements and their dependants: training; study; employment under the General Employment Policy; investment under the General Employment Policy (i.e. to establish or to join in a business); employment under the Admission Scheme for Mainland Talents and Professionals; or employment under the Immigration Arrangements for Non-local Graduates; or (viii) persons under custody (i.e. imprisoned, remanded or detained by the Correctional Services Department on the date of submitting the application under the Programme (see paragraph 3(c) below)). 2. Completing the Application Form and Submitting the Application : (a) (b) (c) (d) The applicant must provide the required information and his/her signature in this Form. Failure to provide the information may result in non-processing of the application by the Community Care Fund (CCF) Secretariat. The applicant is advised to keep a copy of the completed form for future reference. The applicant must have reached the age of 18 when submitting application. The CCF Secretariat will otherwise return the application form to the applicant for re-submission when the applicant reaches 18. From 3 October 2011 to 30 June 2012, the duly completed application form should be (i) sent by post to the CCF Secretariat (address: 6/F, Southorn Centre, 130 Hennessy Road, Wanchai, Hong Kong) with sufficient postage on the envelope (as attached); or (ii) deposited at the drop boxes at the Public Enquiry Service Centres (PESCs) of the Home Affairs Department (HAD). Each applicant should submit only one application form and ensure accuracy of the information provided. Duplicate submissions or subsequent amendment of information therein may delay the processing of application and disbursement of allowance. Duplicate submissions will not be processed. This application form, once submitted, cannot be withdrawn except with valid reasons. For mentally incapacitated persons who are unable to submit an application, their legal guardians (i.e. those appointed under the Mental Health Ordinance (Cap. 136)), appointees receiving CSSA for them or relatives should call the CCF Secretariat at 3118 1818 for special arrangement. The applicant must submit copies of the following supporting documents together with the application form: Copy of HKIC or Acknowledgement of Application for a HKIC (may choose to produce the original copy in person at CCF Secretariat); Copy of One-way Permit (for applicants who have entered Hong Kong from the Mainland on One-way Permit); Copy of valid dependant visa/entry permit (for applicants who are staying in Hong Kong legally as dependants); Copy of Hong Kong Permanent Identity Card/HKIC of the sponsor of the application for dependant visa/entry permit (for applicants who are staying in Hong Kong legally as dependants); (if applicable) For applicants who choose to receive the allowance through direct payment into bank accounts, please provide copies of supporting documents of the bank accounts (e.g. the relevant page of passbook showing the name of the account holder, bank card or bank statement, etc. of the bank account concerned); (if applicable) For applicants/family members residing with the applicants who have passed the family/household-based means-test of the specified assistance schemes, please provide copies of relevant supporting documents as listed in Note 3. If it is the family member who applied for the scheme concerned, please provide a copy of documentary proof for the relationship of the family member with the applicant (e.g. marriage certificate or birth certificate, etc.).

(e)

(f)

(g)

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3.

Processing of Application : (a) The CCF Secretariat will vet every application, including verifying the applicants eligibility and checking the supporting documents submitted by the applicant. The CCF Secretariat may contact the applicants regarding the information on the application forms. Applicants may be required to clarify or submit additional information. The CCF Secretariat will conduct audit checks on individual cases in the course of processing of application or after the disbursement of allowance. The applicants concerned will be required to provide additional information or produce the original copies of the supporting documents in person at the CCF Secretariat for checking. Applicants may also be requested to refund the amount as certified by the CCF Secretariat as overpayment or payment by mistake. Postmark date on the envelope will be regarded as the date of submission of those application forms by post. For application forms deposited at the drop boxes at the PESCs of the HAD, the date the CCF Secretariat receives the application forms from the PESCs will be regarded as the date of submission. The CCF Secretariat will issue a notification of result to applicants after vetting the applications concerned. Notifications to unsuccessful applicants will be sent by registered mail. Applicants who disagree with the application results can appeal in writing with justifications within 7 days after receiving the notifications. All appeals against application results will be handled by a group comprising members from the committees under the CCF. The decision of the group shall be final.

(b)

(c)

(d)

4.

Disbursement of Allowance : (a) (b) The CCF Secretariat will disburse an allowance of HK$6,000 to eligible applicants. For applicants who choose to receive the allowance through direct payment into bank accounts, the allowance will be deposited directly into their bank accounts as specified in their application forms through autopay. The applicants must provide the account number of his/her local Hong Kong dollar sole-name savings/current account. Do not provide the account number of a joint account, credit card account, loan account, fixed deposit account or foreign currency account. For applicants who choose to collect the allowance in the form of order cheques, they shall bring along their identity documents and collect the cheques in person at the CCF Secretariat within the period and time specified in the notification of result. The order cheque will be issued to an applicant after verification of his/her name and identity card number. If applicants fail to collect the cheques within the specified period and time without reasonable explanations, no allowance will be given to them.

(c)

5.

Enquiry : For details of the Programme, please visit the CCFs website (http://www.communitycarefund.hk) or call 3118 1818.

Community Care Fund

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Appendix 2(A) Personal Information Collection Statement (Applicable to applicants)

Purpose of Collection 1. The information provided in this application form (this Form) and other information that may be provided for the purposes of the Programme (the Data) will be used by the Community Care Fund (CCF) Secretariat and its agents/contractors for one or more of the following purposes and any directly related purposes in respect of the Programme: (a) to process your application and receipt of payment, if applicable, under the Programme (including but not limited to the process(es) referred to in Part 5 of this Form) and, if required, to communicate with you for matters relating to the Programme; to conduct matching between the Data and the personal data held by the Government (including but not limited to the Immigration Department and the Correctional Services Department) to check your eligibility under the Programme; to administer the Programme including but not limited to effecting payment to you, issuing written notifications to you and conducting investigations referred to in paragraph 4 in Part 5 of this Form; for statistics purposes on the condition that the resulting statistics will not be made available in a form which will identify the data subjects or any of them; and any other purposes as may be required, authorised or permitted by law.

(b)

(c) (d) (e)

2. The provision of the Data is voluntary, but if you do not provide sufficient and accurate data, the CCF Secretariat may not be able to process your application and may disqualify your application. Classes of Persons to Whom the Data may be Transferred 3. For the purpose stated in this Form, the CCF Secretariat may transfer the Data to the committees under the CCF and/or its agents/contractors (e.g. banks) and/or relevant bureaux/departments of the Government, including but not limited to the Immigration Department, the Correctional Services Department and other transferees and any other parties as stipulated in Part 5 of this Form. Access to Personal Data 4. Except where there is an exemption provided under the Personal Data (Privacy) Ordinance (Cap. 486), you have the right to request access to and correction of the Data when they have not been erased. Your right of access includes the right to obtain a copy of the Data subject to the payment of a fee. Access and Correction Requests on Personal Data 5. Your requests for access to personal data or enquiry on the personal data privacy policy, and your requests for correction of data obtained from a data access request should be addressed to: Post Address : : Executive Officer (Community Care Fund)2 Community Care Fund Secretariat 6/F, Southorn Centre, 130 Hennessy Road, Wanchai, Hong Kong 2835 1301

Tel. No.

Community Care Fund

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Appendix 2(B) Personal Information Collection Statement (Applicable to sponsors of those applicants staying in Hong Kong legally as dependants)
Purpose of Collection 1. The information relating to you provided in this application form (this Form) and other information relating to you that may be provided for the purposes of the Programme (the Data) will be used by the Community Care Fund (CCF) Secretariat and its agents/contractors for one or more of the following purposes and any directly related purposes in respect of the Programme: (a) to process the applicants application and receipt of payment, if applicable, under the Programme (including but not limited to the process(es) referred to in Parts 5 and 6 of this Form) and, if required, to communicate with you for matters relating to the Programme; to conduct matching between the Data and the personal data relating to you held by the Government (including but not limited to the Immigration Department) to check the applicants eligibility under the Programme; to administer the Programme and conducting investigations referred to in paragraph 4 in Part 5 and paragraph 4 in Part 6 of this Form; for statistics purposes on the condition that the resulting statistics will not be made available in a form which will identify the data subjects or any of them; and any other purposes as may be required, authorised or permitted by law.

(b) (c) (d) (e)

2. The provision of the Data is voluntary, but if you do not provide sufficient and accurate data, the CCF Secretariat may not be able to process the applicants application and may disqualify the application concerned. Classes of Persons to Whom the Data may be Transferred 3. For the purpose stated in this Form, the CCF Secretariat may transfer the Data to the committees under the CCF and/or its agents/contractors and/or relevant bureaux/departments of the Government, including but not limited to the Immigration Department and other transferees and any other parties as stipulated in Part 6 of this Form. Access to Personal Data 4. Except where there is an exemption provided under the Personal Data (Privacy) Ordinance (Cap. 486), you have the right to request access to and correction of the Data when they have not been erased. Your right of access includes the right to obtain a copy of the Data subject to the payment of a fee. Access and Correction Requests on Personal Data 5. Your requests for access to personal data or enquiry on the personal data privacy policy, and your requests for correction of data obtained from a data access request should be addressed to: Post Address : : Executive Officer (Community Care Fund)2 Community Care Fund Secretariat 6/F, Southorn Centre, 130 Hennessy Road, Wanchai, Hong Kong 2835 1301

Tel. No.

Community Care Fund

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