弱能儿童前服-SocialWelfareDepartment社会福利署.DOC

SWD/CLEIC Form 1 Annex 1社会福利署SOCIAL WELFARE DEPARTMENT暴力及执法伤亡赔偿计划申请表 SWD/CLEIC Form 1 Annex 1 CRIMINAL AND LAW ENFORCEMENT INJURIES COMPENSATION SCHEME APPLICATION FORM 受害人／申请人须知： 请参阅赔偿计划小册子，然后签署填妥的申请表，连同受害人的身份证明文件副本一并寄回。 Notice to victim/applicant: Please read the leaflet of the compensation scheme and then complete, sign and return this application form together with a photocopy of the victims identity document. 本人拟申请*暴力／执法伤亡赔偿，有关案件发生于 (日期) 地点为 I wish to apply for *Criminal/Law Enforcement Injuries Compensation in respect of an incident occurring on at 该案件已呈报 警署，报案日期为 案件编号 The incident was reported to Police Station on . Case no. 受害人曾接受 医院／医生治疗。 Victim had been treated by Hospital/doctor. 受害人的个人资料PARTICULARS OF VICTIM 姓名 中文姓名电码 性别 Name (英文) (中文) CCC Sex 身份证明文件号码 出生日期 年龄 职业 Identity Document No. Date of Birth Age Occupation 住址 住所电话 Home Address Home Tel. 通讯地址 办公室电话 Correspondence Address Office Tel. 简述案件发生经过 Brief Description of Incident 申请人的个人资料PARTICULARS OF APPLICANT (适用于受委人，死者的遗属，或十八岁以下受害人的监护人)(Applicable to appointee, deceaseds surviving dependant, or guardian of victim under the age of 18) 姓名 中文姓名电码 Name (英文) (中文) CCC 身份证明文件号码 性别 年龄 职业 Identity Document No. Sex Age Occupation 住址 住所电话 Home Address Home Tel. 通讯地址 办公室电话 Correspondence Address Office Tel. 与受害人的关系 Relationship to Victim 本人同意 (医生姓名／医院名称) 就本申请向社会福利署提供有关*本人／受害人医疗情况的资料。 I consent to the release of information on *my/the victim’s medical condition by (Name of Doctor/Hospital) to the Social Welfare Department for the purpose of this application. 本人同意香港警务处就本申请向社会福利署提供有关*本人／受害人的警方报告或其他资料。 I agree to the Hong Kong Police Force providing the police report or other pertinent information on *me/the victim to the Social Welfare Department for the purpose of this application. 本人现声明据本人所知，以上的资料全属正确。本人明白凡蓄意提供虚假资料或漏报资料，或错误引导社会福利署，以图骗取*暴力／执法伤亡赔偿乃属刑事行为，除可导致申请人或受害人丧失领取赔偿的资格外，并可能根据香港法例第210章(盗窃罪条例)而被起诉。任何触犯盗窃罪的人士，循公诉程序定罪后，可判监10年。 I declare that to the best of my