Aid Application Form/援助申請表格
姓名/Name：(中) ______________________(英)______________________
性別/Gender：□ 男 Male/□ 女/Female 年齡/Age : ________________
婚姻狀況Marital Status: □單身/Single □已婚/Married □離婚/Divorced
身份証/報身紙號碼：_______________ 出生日期/BOD：_________________
職業/Occupation：______________ 每月收入/Monthly Income：_______
(請呈上收入証明/Please attach the pay slip or J-form )
地址 Address：_____________________________________________________
_____________________________________________________
電話/Tel:(住家Home)_____________(手提H/P)______________
求助原因/Reason of Appeal： ________________________________________
有福利部援助金? Do you currently receive support from Kebajikan?
□ 有/Yes, RM_____________ /月per month □ 無/No
申請者是否有/計劃向其他機構或媒體申請金錢支援？□有/Yes □ 無/No
Are you approaching/intend to any other organization(s) for donation?
家庭成員資料 / Family Members Details
姓名/Name 身份証/報生紙/ID No. 關係/Relationship 職業/Occupation
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
5. ______________________________________________________
居所 /Accommodation
□ 花園屋 Detached/Terrace □ 組屋 Flat □ 公寓 Apartment
□ 新村屋 Village □ 木屋 Wooden House
需要供屋/租屋? House Installment/House Rented? □是/Yes □否/No
如需供屋/租屋, 每月的分期付款/租金數額?/If the house is under installment/rented,
what amount of installment/rental is paid per month? RM______________/月 per month
交通工具 / Transportation
□ 汽車/Car □ 摩哆車/Motorcycle □ 貨車/Van □ 其他 Other:_______
車款/Type of transport : _____________車牌/Car No:_____________
需要供車? Car Installment? □是/Yes □否/No
如需供車, 每月的分期付款數額? If the car is under installment,
what installment amount is paid monthly? RM___________ /月 per month
委託人資料/Information of Consignor
姓名/Name：(中)_____________________ (英)______________________
身份証/報身紙號碼/ID No.:______________ Relationship:___________
地址/Address：______________________________________
_______________________________________________
電話Tel：(住家Home)________________ (手提 H/P): _______________
職業/Occupation ：________________ 每月收入/Montly Income:_______
請附上以下文件 Please attach the following:-
1. 申請者身份証/報身紙影印本/NRIC or birth cert of the applicant
2. 申請者照片 /Photo of the applicant
3. 家庭成員的身份証/報生紙複印本/I/C or birth cert of applicant’s family members
4. 最近三个月的水电费單据, 電話單及屋租單/The latest 3 months electricity, water, telephone bill and rental receipt
调查日期：__________ 调查員：____________ 签名:_________
CCEP扶貧基金会申請援助指南
為了確保申請醫藥/生活援助者是真正需要公眾捐款的人士，申請者必須先呈上資料完整的申請表格，並提供以下文件：
1．申請人和其家人的收入證明：
*最新的薪金單（pay slip/Socso)
*雇員公積金月單
*租屋單據，電話單據，水電單據等
2．成人病患的身分證復印本，或病患家中成員的身分證/報生紙復印本，十二歲以下的孩童的報生紙復印本。
3．醫藥報告的正本(最近6個月)，由專業醫生建議的醫療方式及有關治療的預算費用申請醫藥費。
申請短期生活補助費/短期生活援助金
1．因家貧或因意外，患病，單親而申請援助金者必須提呈每月的生活開銷列表。
申請者必須沒有獲得其他團體如Socso/雇員公積金、保險、福利部或其他慈善團體的財物援助。
撥放義款方式
1．申請醫藥費的案例：義款是直接支付給醫院。
2．申請短期生活援助金的案例：
將由CCEP扶贫基金会負責去了解/確定申請者的需求（故申請者需提呈一份每月的生活開銷列表供參考）。視CCEP扶贫基金会深入了解，調查之后的結論決定是否接受或批準，然后按月撥出援助金給申請者。
3．申請者簽了申請表格后，即表示同意與CCEP扶贫基金会配合，賦予CCEP扶贫基金会全權處理的權力。若有被發現有欺騙的成分存在，CCEP扶贫基金会將會停止撥款。
注：CCEP扶貧計劃協會保留一切增刪的權力
CCEP Foundation Application Guide
To ensure that applicants for medical/living assistance are those who are really in need, applicants must submit a complete application form and provide the following documents:
1. Proof of income of the applicant and his family:
*The latest salary slip (pay slip)/Socso
*Employee EPF copy
* Rental bills, telephone bills, water and electricity bills, etc.
2. A photocopy of the identity card of an adult patient, a copy of the identity card/reproduction paper of a member of the patient’s home, and a copy of the birth certificate of a child under the age of 12.
3. The original medical report (in the last 6 months), the medical expenses recommended by the doctor, and the budget for the treatment.
Apply for short-term living assistance
1. If the applicant has an accident, or sickness, and is a single parent, must submit a monthly list of living expenses.
Applicants must not receive financial assistance from other groups such as Socso/Employees Provident Fund, Insurance, Welfare Department, or other charities.
Funds release method
1. Case for applying for medical expenses: The payment is paid directly to the hospital.
2. Case for applying for short-term living assistance:
It is the responsibility of the CCEP Foundation to understand/determine the applicant’s needs (so applicants are required to submit a monthly list of living expenses for reference). Depending on the CCEP Foundation’s in-depth understanding, the conclusions after the investigation decide whether to accept or approve, and then allocate assistance to the applicant monthly.
3. After the applicant has signed the application form, it agrees to cooperate with the CCEP Foundation and gives the CCEP Foundation the right to handle it. If a component is found to be fraudulent, the CCEP Foundation will stop funding.
Note: CCEP Foundation reserves all the rights for additions and deletions.