Labour Department

1. Residential Address

2. Correspondence Address (if different from the residential address above)

3. No. of Household Members person(s)

4. Claim Period for Subsidy (month/year) From / 201 / 201(must be previous six to 12 months)

5.

6. If the composition of the household has changed during the "Claim Period for Subsidy", please specify the date and details of change

(2018)

1. Name (Surname first, then other names)

Household Application Form

Work Incentive Transport Subsidy Scheme

If the household has moved during the "Claim Period for Subsidy", please specify the date of relocation and previousaddress

Part 1 Household Particulars of Applicant(s)

Yes / NoYes / No

Male / Female

Part 2 Particulars of All Household Members

to

If your household has applied for Work Incentive Transport Subsidy (WITS) before and the particulars of the householdmembers remain the same as those provided in the last application, the part(s) in grey need not be completed. If there aremore than four household members, please provide their particulars in Supplementary Sheet.

First ApplicantFourth Applicant /

Household Member

2. Apply for Subsidy? #

5. Sex #

If it is inconvenientto receive phone callfrom LabourDepartment in aparticular period oftime, please specify(e.g. 9am to 10am)

10.

Third Applicant /Household Member

Second Applicant /Household Member

Spouse / Child / Parent

# Please circle the appropriate item.

Male / Female Male / Female

3. Identity Document No.

7. Local Mobile Phone No.

4. Date of Birth (month/year)

Yes / NoYes

Spouse / Child / ParentMale / Female

Spouse / Child / Parent

Others ____________6. Relationship with First Applicant # Others ____________

Not ApplicableOthers ____________

In Employment

8. Other Phone No.

Full-time / Part-time /Not in Employment /

Retired

9. Employment Status during the "Claim Period for Subsidy" #

Full-time / Part-time /Not in Employment /

Retired

Full-time / Part-time /Not in Employment /

Retired

2

Please put a "" in the appropriate box. @ Claim months may range from the previous six to 12 months.* without decimal places and in exact amount

Please provide information of other applicant(s) in Supplementary Sheet.

1. Full-time student or trainee not in employment during the "Claim Period for Subsidy"?If yes, please specify the education / training programme and the period

2.

Name of Bank Account No.

(A) Earnings from Employment of First Applicant (including part-time employment)

1. Name of Company/Employer 2. Post 3. Industry

4. Detailed Address of Main Workplace 5. Company/Employer's Telephone No.

6. Any commuting to and from work on a self-paying basis? Yes No 7. Self-employed? Yes No

/201 /201 /201 /201 /201 /201

/201 /201 /201 /201 /201 /201

(B) Earnings from Employment of Household Members not applying for WITS(including part-time employment)

1. Name of Household Member 2. Post

3. Name of Company/Employer 4. Industry

/201 /201 /201 /201 /201 /201

/201 /201 /201 /201 /201 /201

No

Bank Account No. for receiving subsidy (Applicant must be the account holder. Please provide copy of the monthlybank statement / passbook which shows the holder's English name and the account number.)

Yes

Part 4 Household Income

Claim Months

(month/year) @

(Please refer to paragraph 4 of Part B in theGuidance Notes on Household-based Applications .)

Working Hoursin that month

Earnings(HK$)*

Claim Months(month/year) @

Earnings(HK$)*

Claim Months(month/year) @

Working Hoursin that month

Earnings(HK$)*

Earnings(HK$)*

(If space is insufficient, please provide additional information in Supplementary Sheet.)

Please fill in all the earnings from employment and relevant information in each claim month. If your householdhas other applicant(s) or you have more than one job or have changed job during the "Claim Period for Subsidy",please provide additional information in Supplementary Sheet.

Part 3 Information of First Applicant

If you have applied for WITS before and the particulars remain the same as those provided in the last application, thepart(s) in grey need not be completed.If you have applied for WITS before and the particulars remain the same as those provided in the last application, thepart(s) in grey need not be completed.

Claim Months(month/year) @

3

Claim months may range from the previous six to 12 months. * without decimal places and in exact amount

(C) Other Income of All Applicant(s) and Household Members

/201 /201 /201 /201 /201 /201

/201 /201 /201 /201 /201 /201

1.

/ /201

/ /201

/ /201

/ /201

/ /201

/ /201

/ /201

2.

received CSSA

Please put a "" in the appropriate box.

1.

2. Yes No

Part 6 Declaration on Household Income and Assets

(Please refer to paragraph 5 of Part B in theGuidance Notes on Household-based Applications .)

Part 5 Household Assets

Did the household assets in each claim month meet the monthly asset limit of the Scheme?

Please provide information on all assets of all applicant(s) and household members within and outside HongKong in the last claim month e.g. bank deposits in all personal, joint and / or company accounts, cashsavings, stocks, cash value of insurance policies (including dividends), loans to others, etc.

Name of Owner

If your household has received "Comprehensive Social Security Assistance" (CSSA) during the "ClaimPeriod for Subsidy", please put a "" in the box and provide copy of the notification of approval of CSSAapplication and the Certificate of CSSA Recipients (for Medical Waivers).

Date of Value(day/month/year)

Description of Asset e.g. Deposits (Name of Bank) Insurance (Name of Company)

(If space is insufficient, please provide additional information in Supplementary Sheet.)

@

Value (HK$)*

Yes

Name

NoHave all applicant(s) and household members reported all the earnings from employment,other income and assets?

Claim Months (month/year)@ and Amount (HK$)*Description ofIncome

(e.g. monthly pension, rental income, contributions from relatives / friends not residing together)

4

(1)

(2)

(3)

(4)

(If there are more than two applicants, please make additional copy of this page for signature.)

I/We authorise, and confirm that each of the household members not applying for WITS agrees toauthorise, other divisions of the Labour Department, relevant government bureaux / departments,Hong Kong Housing Society, banks, insurance companies, employers, Mandatory Provident FundSchemes Authority, mandatory provident fund scheme trustees, Hong Kong Jockey Club and otherconcerned parties to release the personal data and records of me/us and the household members notapplying for WITS, and information of companies under my/our name(s) and names of householdmembers not applying for WITS to the Labour Department and its authorised bodies for the purposeof processing this application and verifying any information in relation to this application.

I/We understand that wilfully or knowingly making false statement, misrepresentation orconcealment of any information in order to obtain the subsidy by deception is a criminal offence. Inaddition to the consequence of being ineligible for the subsidy, I/we may be prosecuted forcontravening the Theft Ordinance (Cap. 210) and be liable on conviction to imprisonment for amaximum of 14 years. I/We also undertake to refund any overpaid subsidy, and agree that theconcerned overpaid amount be offset by the Government of the Hong Kong Special AdministrativeRegion against any subsidy approved in my/our future applications.

Part 7 Declaration by Applicant(s)

I/We have read the Guidance Notes on Household-based Applications under the Work IncentiveTransport Subsidy Scheme (Guidance Notes on Household-based Applications) and the monthly incomeand asset limits of the Work Incentive Transport Subsidy Scheme and relevant information in respect ofthe Working Family Allowance in the Additional Information for Guidance Notes on Applicationsunder the Work Incentive Transport Subsidy Scheme. I/We understand and agree to the arrangements inrelation to the application such as vetting procedures, payment of subsidy, etc. I/We hereby undertakeand warrant that I/we shall comply with all requirements set out in the Guidance Notes on Household-based Applications in making this application, and declare the following:

The information provided in this application form and (if any) Supplementary Sheet and therepresentations and supporting documents submitted by me/us are true, complete and accurate.I/We undertake to report any change of information provided in this application and submit relevantinformation to the Labour Department as soon as possible for consideration by the LabourDepartment regarding my/our eligibility for WITS.

Each applicant applying for the Work Incentive Transport Subsidy (WITS) must read and sign thedeclaration below.

Name of Applicant(s) Signature Date

I/We confirm that each of the household members not applying for WITS has authorised me/us tosubmit their personal data to the Labour Department in relation to this application. I/We giveconsent, and confirm that each of the household members not applying for WITS consents, to theLabour Department and its authorised bodies to handle and use the personal data provided by me/usand the household members not applying for WITS in this application in accordance with paragraph5 of Part A "Details of the Scheme and Application" of the Guidance Notes on Household-basedApplications and to verify and disclose the related personal data and information of companiesunder my/our name(s) and names of household members not applying for WITS to the concernedparties, and the Labour Department to liaise with household members not applying for WITS toverify or clarify their data.