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(A) Estimated Medical Expenses (For Applicant) : Declaration Form F

This declaration form requests information about an applicant's estimated monthly medical expenses for themselves or family members with medical conditions to support their application for financial aid, requiring the applicant to submit supporting documentation and sign declaring the information is true. Incomplete forms or late submissions could affect the processing of the financial aid application.

Uploaded by

Yash Gupta
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
36 views

(A) Estimated Medical Expenses (For Applicant) : Declaration Form F

This declaration form requests information about an applicant's estimated monthly medical expenses for themselves or family members with medical conditions to support their application for financial aid, requiring the applicant to submit supporting documentation and sign declaring the information is true. Incomplete forms or late submissions could affect the processing of the financial aid application.

Uploaded by

Yash Gupta
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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DECLARATION FORM F

This form is to be completed by applicant who he/she or family member(s) has medical condition(s).
All information must be clearly stated as required.
This form must be submitted with other supporting documents (if applicable) upon completion of online financial aid application by
the applicant / student.
Incomplete form or late submission of form will affect the processing of the financial aid application.

Name of Applicant:

(A)

Application/Student No.:

ESTIMATED MEDICAL EXPENSES (for applicant)

Name of medical condition(s) and/or disability*:

Estimated medical expenses per month for


illness or disability:

$
(No conversion of currency is required)

(B)

ESTIMATED MEDICAL EXPENSES [for family member(s)]

Note: If you have more than one family member with medical condition, please indicate their combined
estimated medical expenses below.

Name of medical condition(s) and/or disability*:

Estimated medical expenses per month for


illness or disability:

$
(No conversion of currency is required)

(C)

(D)

SUPPORTING DOCUMENT STATUS (Please tick where applicable)


I have attached a copy of report/any document stating medical condition from a certified
general practitioner / doctor, if available
I have attached a copy of the relevant medical bills for the past 3 months, if available.

DECLARATION

I confirm that all the information stated in this form is true and I have not willfully suppressed or
misrepresented any material fact pertaining to this confirmation.

Signature of applicant

Date

*Delete accordingly

Office of Admissions (Attn: Office of Financial Aid)


Original copy accepted only
National University of Singapore, University Town
2 College Avenue West, #01-03 (Stephen Riady Centre), Singapore 138607
Tel: (65) 65162870 Fax: (65) 67744021
Email: [email protected]
OFA-FormF-04/13

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