Application for Claim of Handicapped-Related Tax Reliefs

This form must be completed and submitted to IRAS if you are claiming the handicapped-related tax relief(s) for the first time. If you have provided the handicap details to IRAS previously you do not have to submit the form to IRAS. This form may ta!e you " minutes to fill in. #lease have your dependant$s and your personal particulars %ith you. #lease note that Section & should be completed by doctor(s) registered %ith the Singapore 'edical (ouncil. )or doctor assessment(s) please bring along your* the dependant$s medical reports and* or medications. #lease note that you may incur administrative* medical assessment fees for this form to be completed by the registered doctor.

Section 1 Your Personal Particulars )ull name+ ,'r* 'rs* 'iss* 's Address+ #ostal (ode+ Telephone+ (.) (.#) (/) ,-RI(* )I-* #assport -o+

Section 2 Type of Handicapped-related Relief you are claiming (i) #lease tic! the type of handicapped-related relief you are claiming for+ Self (ii) Spouse (hild #arent 0 Staying Together #arent 0 -ot Staying Together 1rother* Sister

#lease provide details of your dependant+ ,-RI(* )I-* #assport -o+ Relationship to you+

)ull name+ ,'r* 'rs* 'iss* 's 2ate of 1irth+ Section * * Sex+ ,'ale* )emale

Comments !y "octor (to be completed by doctor who is providing information on the case )

Please complete Part #A$ if t%e indi&idual suffers from p%ysical %andicap or Part #'$ if t%e indi&idual suffers from mental disa!ility(disorder) Part #C$ s%ould !e completed for A** cases) #art (A) 0 )or physical handicap cases+ (i) (ii) The individual stated in Section 3 above suffers from (#lease state type of physical handicap e.g. blindness or deafness) #lease complete the follo%ing Acti&ities of "aily *i&ing 4ashing or 1athing 5Ability to bathe or sho%er (including getting into and out of the bath or sho%er) or %ash by other means6 2ressing 5Ability to put on ta!e off secure and unfasten all garments (upper and lo%er) and any braces artificial limbs or other surgical appliances6 Please Select -o help is needed -eeds help*supervision most of the time "octor+s Remar,s

-o help is needed -eeds help*supervision most of the time

)eeding 5Ability to feed oneself after food has been prepared and made available6

-o help is needed -eeds help*supervision most of the time

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Acti&ities of "aily *i&ing Toileting 5Ability to use the toilet or manage bo%el and bladder function through the use of protective undergarments or appropriate surgical appliances6

Please Select

"octor+s Remar,s

-o help is needed -eeds help*supervision most of the time

Transferring 5Ability to move from (a lying position on the) bed to an upright chair or %heelchair and vice versa6

-o help is needed -eeds help*supervision most of the time

'obility 5Ability to move indoors from room to room on level surfaces6

-o help is needed -eeds help*supervision most of the time

#art (1) 0 )or mental handicap cases+ (i) (ii) The individual stated in Section 3 above suffers from (#lease state type of 'ental 2isability*2isorder e.g. Schi=ophrenia 2ementia 'ental Retardation etc) #lease complete the follo%ing Acti&ities Is the individual impaired in Self (are and Activities of 2aily >iving? 5Ability to care for self and independently manage activities of daily living ( i.e. %ashing*bathing dressing feeding toileting transferring mobility)6 Is the individual impaired in compliance to #sychiatric Treatment? 5Ability to ta!e medications and comply %ith prescribed psychiatric treatments6 Is the individual impaired in Aducation or 4or!? 5Ability to integrate into the normal stream of education or to sustain gainful employment6 #art (() 0 To be completed for all cases (i) (ii) (iii) The ,mental* physical handicap has commenced since (yyyy). The ,mental* physical handicap ,is* is not permanent. The status of ,mental* physical handicap is expected to change %ithin BBBBBB years. Please Select @es -o "octor+s Remar,s

@es -o

@es -o

Additional comments (if any)+

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-ame of 2octor (ontact -o.

, 2elete %here applicable

/fficial stamp of clinic* hospital 2ate

Signature of 2octor

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Telephone -o.+ ;:77-&"<:&77

)ax -o.+ <&";&<&<

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