BORANG PERMOHONAN BAYARAN TAMBANG SETIAP EMPAT (4) TAHUN ... - Judiciary

[Pages:2]BORANG PERMOHONAN BAYARAN TAMBANG SETIAP EMPAT (4) TAHUN APPLICATION FORM FOR FARE ALLOWANCE EVERY 4 YEARS

PERHATIAN: SILA LENGKAPKAN BORANG INI DENGAN KETERANGAN YANG BETUL DAN JELAS ATTENTION: PLEASE COMPLETE THIS FORM WITH CORRECT AND CLEAR INFORMATION

Kepada: To:

Timbalan Penerima Rasmi / Deputy Official Receiver

Pejabat Penerima Rasmi / Office of Official Receiver

Mahkamah Besar

/ Supreme Court

Perkara: Matter:

Kebankrapan No. ___________________________________ Bankruptcy No.

A. Maklumat Pemohon: Information of Applicant:

Nama Penuh: Full Name: Nombor dan warna IC: Number and Colour of Identity Card: Alamat dan Poskod: Address and Postcode:

No. Telefon Rumah/Bimbit Home Telephone No. / Mobile No.:

B. Awang/Dayang membuat permohonan untuk: Application made for:

Perbelanjaan Kanak-Kanak Sekolah (seperti buku, alat tulis, pakaian seragam) Children's School Expenses (e.g. Books, Stationery, uniform) Perbelanjaan Kereta (seperti kos membaiki kereta, pembayaran cukai `Road Tax',bayaran insuran) Car Expenses (e.g. Fixing, Tax Payment, Insurance Payment) Perbelanjaan pengubahsuaian Rumah Home Renovation Expenses Yuran Peperiksaan Examination Fees Perbelanjaan lain (sila jelaskan di bawah): Other Expenses (Please state below):

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

C. Sila senaraikan perkara-perkara yang dipohankan: Please list down matters applied for: Bil. Perkara-perkara yang dipohonkan Matters applied for 1.

2.

3.

4.

5.

Jumlah yang Dipohonkan Amount $

$

$

$

$

BORANG PERMOHONAN BAYARAN TAMBANG SETIAP EMPAT (4) TAHUN APPLICATION FORM FOR FARE ALLOWANCE EVERY 4 YEARS

6.

$

7.

$

8.

$

9.

$

10.

$

D. Sila nyatakan sebab-sebab mengapa Awang/Dayang membuat permohonan tersebut: Please state reasons for application:

Saya mengakui bahawa maklumat/keterangan yang dinyatakan diatas adalah benar. Jika tidak, saya boleh didakwa dibawah seksyen 129, Akta Kebankrapan (BAB 67) bagi kesalahan penipuan. Jika didapati bersalah, hukuman adalah dua tahun penjara.

I, hereby acknowledge that the information / description stated above are true. If not, I am liable to be charged under section 129, Bankruptcy Act (Chapter 67) for the offence or cheating. If found guilty, the sentence is two years imprisonment.

Tandatangan Pemohon: Signature of applicant:

Tarikh: Date:

** SILA PASTIKAN BORANG PERMOHONAN INI DISERTAKAN DENGAN SALINAN DOKUMEN-DOKUMEN YANG AKAN MENYOKONG PERMOHONAN AWANG/DAYANG SEPERTI:

Please ensure that this application form is attached with copies of document that support your application such as:

1. SENARAI PERBELANJAAN / LIST OF EXPENSES 2. BUKU BANK / SAVING ACCOUNT BOOK 3. SLIP GAJI / SALARY SLIP

4. RESIT RASMI / OFFICIAL RECEIPT

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