Read S6K-2(E), page 2 @ Preflight ( 221201541_S6K-2(E).indd.ps, page 1 @ Preflight ) text version

"Scheme $6,000" Registration Form (For Cheque Payment to Registrant)

Note : 1. Please read the "Scheme $6,000" Guidance Notes overleaf before completing this registration form ("this Form"). 2. Please complete this Form in BLOCK letters using black or blue pen.

Part 1 Personal Particulars of Registrant

( ) Local Contact Telephone No. Chinese Name (if applicable) English Name as shown on the HK Permanent Identity Card Local Correspondence Address Reference No. (For Hongkong Post Use Only)

2

HK Permanent Identity Card No.

#

HK / KLN / NT

Part 2

Cheque Collection Location

Please submit this Form using the "Scheme $6,000" drop-box at any post office or send it by post to "GPO Box 186000, Hong Kong".

I shall collect the cheque at the post office specified below. Post Office Code ( ) Please see overleaf for post office codes and addresses.

Part 3 1. 2.

Declaration and Undertaking of Registrant

3.

4. 5.

6. 7.

I, the undersigned, declare that I am the holder of Hong Kong Permanent Identity Card ("HKPIC") number as given in Part 1 of this Form. I have read the following "Personal Information Collection Statement" and fully understand its content. Personal Information Collection Statement Purpose of Collection p The information provided in this Form and other information that may be provided for the purposes of "Scheme $6,000" ("the Data") will be used by the Government of the Hong Kong Special Administrative Region ("the Government") and its agents/contractors for one or more of the following purposes and any directly related purpose, in respect of "Scheme $6,000" and other scheme(s) if any operated f the same for purpose as "Scheme $6,000" (hereinafter referred to "such scheme(s)"): (i) to process your registration and payment, if applicable, under such scheme(s) (including but not limited to the process(es) referred to in this Part) and if required, to communicate with you for matters relating to such scheme(s); (ii) to conduct matching between the Data and the personal data held by the Government including the Immigration Department to check your eligibility under such scheme(s); (iii) to administer such scheme(s) including but not limited to effecting payment to you, issuing written notifications to you and conducting the investigations referred to in paragraph 4 in this Part; (iv) for statistics purposes on the condition that the resulting statistics will not be made available in a form which will identify the data subjects or any of them; and (v) any other purposes as may be required, authorised or permitted by law. It is voluntary for you to supply the Data but if you fail to supply any of the data required by this Form, your registration may not be processed. Classes of Transferees The Data you provide may be disclosed to relevant bureaux and departments of the Government, their agents/contractors including but not limited to the Treasury, Immigration Department, Hongkong Post, Financial Services and the Treasury Bureau, banks and other transferees and any other parties as stipulated in this Part for the purposes stated in this Form. Access to Personal Data Except where there is an exemption provided under the Personal Data (Privacy) Ordinance (Cap. 486), you have the right to request access to and correction of your personal data provided in this Form when the data have not been erased. Your right of access includes the right to obtain a copy of your personal data provided in this Form subject to payment of a fee. Request and Enquiry q q y Your request for access to personal data or enquiry of personal data privacy policy should be addressed by fax (no. 3752 6641) or by post to "Personal Data Privacy Officer, Scheme $6,000 Secretariat, GPO Box 181234, Hong Kong". I hereby authorise and consent to the use of the Data by the relevant bureaux and departments, including their agents/contractors operating in or outside Hong Kong, of the Government to process my registration and receipt of payment under such scheme(s) and for any purpose directly related to such purposes. Such bureaux/departments of the Government include, but are not limited to, the Treasury, Immigration Department, Hongkong Post, Financial Services and the Treasury Bureau, and other relevant government offices involved in the administration and operation of such scheme(s). I also consent to the use of the Data for any checking and/or investigation relating to my registration and receipt of payment under such scheme(s) to be carried out by the relevant bureaux/departments of the Government mentioned in paragraph 3 above, including their agents and contractors, and that they may disclose the Data to any other parties if the disclosure is necessary for such checking and/or investigation. I also consent to the matching of the Data with my personal data held by the Immigration Department (including but not restricted to personal data kept under the Registration of Persons Ordinance (Cap. 177)) and/or other bureaux/departments and/or their agents/contractors in relation to my registration and receipt of payment under such scheme(s), and understand that the matching procedure is conducted for ascertaining whether I am eligible under such scheme(s) or not, and therefore I will not receive payment under such scheme(s) in case I am ineligible. I agree and undertake to notify the Government forthwith of any overpayment to me under such scheme(s) and refund to the Government such amount as certified by the Government as overpayment. I declare that the Data is true and correct. I understand that if I knowingly or wilfully make any false statement or withhold any information, or otherwise mislead the Government for the purpose of obtaining payments under such scheme(s), it will render me liable to prosecution.

Date ___________________________________________________

S6K-2(E)

Signature of Registrant _________________________________________________________

# Delete whichever is inappropriate.

HKSAR Government

"Scheme $6,000" Guidance Notes

1. Eligibility Criteria The registrant should fulfil the eligibility criteria for "Scheme $6,000" ("the Scheme"), i.e., as at 31 March 2012, he/she is: (i) a holder of a valid Hong Kong Permanent Identity Card (i.e. a smart Hong Kong Permanent Identity Card issued on or after 23 June 2003); and (ii) aged 18 or above. For details, please visit the Scheme website www.scheme6000.gov.hk or call the Enquiry Hotline 186 000. 2. Registration (i) This registration form ("this Form") is applicable to registrants who do not have a local Hong Kong dollar sole-name savings/ current bank account. (ii) The registrant must provide the required information and his/her signature in this Form. Failure to provide the required information may result in non-processing of this Form. A local correspondence address should also be provided for receipt of notification in relation to the registration. The registrant is advised to make reference to the sample below. (iii) The duly completed Form should be submitted on or before 31 December 2012: - through the "Scheme $6,000" drop-box in any post office; or - in an envelope with stamp affixed, and addressed to "GPO Box 186000, Hong Kong". (iv) Each registrant should submit only ONE Form under the Scheme and ensure accuracy of the information provided. Duplicate submissions will not be processed. This Form, once submitted, cannot be withdrawn except with valid reasons. Subsequent amendment of information therein will delay the processing of registration and payment. (v) The Hongkong Post may contact the registrant in respect of the information provided in this Form. Where necessary, e.g. in the event of wrongful submission or incomplete information, the registrant may be requested to make a re-submission. Registrants with their registration completed and eligibility confirmed will be advised to collect a cheque by the Hongkong Post by post. In case the registration is not successful, the Hongkong Post will send a notification by post to the registrant. Enquiries For enquiries, please call the Enquiry Hotline 186 000.

Code Post Office (PO) Address

Hong Kong GPO General Post Office KTN Kennedy Town PO SWN Sheung Wan PO SYP Sai Ying Pun PO HFC Heng Fa Chuen PO KNG King's Road PO SKN Shau Kei Wan PO TKS Tai Koo Shing PO ABD Aberdeen PO ALC Ap Lei Chau PO LTG Lei Tung PO WFU Wah Fu PO CWB Causeway Bay PO HAV Happy Valley PO WCH Wan Chai PO Kowloon GAV Gillies Avenue PO KCY Kowloon City PO KCL Kowloon Central PO MGK Mong Kok PO TST Tsim Sha Tsui PO CSW Cheung Sha Wan PO LKK Lai Kok PO SSP Sham Shui Po PO FSN Fu Shan PO SPK San Po Kong PO KBY Kowloon Bay PO KEA Kowloon East PO NTK Ngau Tau Kok PO

Part 1

3.

Code Post Office (PO)

Address

1/F, Shop No. 106, Fu Shin Shopping Centre, Fu Shin Estate, Tai Po G/F, Tai Po Govt. Offices Bldg., 1 Ting Kok Road G/F, Kam Tin Govt. Offices Bldg., Kam Tin Main Road Shop L122, 1/F, Tin Yiu Plaza, Tin Yiu Estate, Tin Shui Wai Shop B, G/F, 8 Yuen Long Pau Cheung Square, Yuen Long Unit 121-122, G/F, Tip Sum House, Butterfly Estate, Tuen Mun Podium Level, Library and Post Office Bldg., 1 Tuen Hi Road G/F, Shop 63, Commercial Complex, Tai Hing Estate, Tuen Mun G/F, North District Govt. Offices Bldg., 3 Pik Fung Road 112-116 San Fung Avenue, Shek Wu Hui, Sheung Shui Shop No. 35-37, 1/F, Mei Lam Commercial Centre, Mei Lam Estate Unit 2, G/F, Sunshine City Phase 4, 18 On Luk Street 1/F Shatin Govt. Offices, 1 Sheung Wo Che Road G/F, Wing B, Chun Shue House, Lei Muk Shue Estate 1/F, Tsuen Wan Govt. Offices Bldg., 38 Sai Lau Kok Road G/F, Bayview Garden, 633 Castle Peak Road, Tsuen Wan Shop No. 4-10, G/F, Kwai Kin House, Kwai Fong Estate G/F, Lok King House, Lai King Estate, Kwai Chung Shop 1, G/F, Hong Kwai House, Cheung Hong Estate G/F, Sai Kung Govt. Offices Bldg., 34 Chan Man Street Shop 30-32, G/F, Hau Tak Shopping Centre, Hau Tak Estate G/F, Cheung Chau Municipal Services Bldg., 2 Tai Hing Tai Road Shop 12A, G/F, Block C, Discovery Bay Plaza, Discovery Bay G/F & 1/F, 2 Main Street, Yung Shu Wan G/F, Mui Wo Govt. Offices Bldg., 2 Ngan Kwong Wan Road G/F, Govt. Bldg., Wing On Street G/F, Tai O Govt. Bldg., 102 Shek Tsai Po St., Tai O G/F, 6 Mei Tung Street Tung Chung

New Territories 2 Connaught Place, Central FUS Fu Shin PO G/F, Kennedy Town Community Complex, 12 Rock Hill Street TPO Tai Po PO 1/F, Hong Kong Telecom CSL Tower, 322-324 Des Voeux Road Central KMT Kam Tin PO 27 Pok Fu Lam Road TNY Tin Yiu PO G/F, West Car Park Block, Heng Fa Chuen YLG Yuen Long PO Shops 204 and 208, 2/F., Olympia Plaza, 255 King's Road BUT Butterfly PO G/F, Perfect Mount Gardens, 1 Po Man Street, Shau Kei Wan TCL Tuen Mun Central PO Shop G1020-1022, G/F, Kam Sing Mansion, 1-3 T Fung Avenue THG Tai Hing PO Tai G/F, Kam Fung Building, 171 Aberdeen Main Road, Aberdeen FNG Fanling PO G/F, Shop 13-16, Lei Ning House, Ap Lei Chau Estate SWH Shek Wu Hui PO Shop 303, L3, Lei Tung Commercial Centre Phase 1, Lei Tung Estate MEL Mei Lam PO 423-424 Wah Chun House, Wah Fu Estate MOS Ma On Shan PO Shops 1015, 10/F, Windsor House, 311 Gloucester Road SCL Sha Tin Central PO G/F, 14-16 Sing Woo Road, Happy Valley LMS Lei Muk Shue PO 2/F Wu Chung House, 197-213 Queen's Road East TSW Tsuen Wan PO TWW Tsuen Wan West PO G/F, 140 Gillies Avenue North, Hung Hom KWF Kwai Fong PO G/F, 28 Lung Kong Road, Kowloon City LKG Lai King PO G/F, Kowloon Government Offices, 405 Nathan Road, Yau Ma Tei TYI Tsing Yi PO 1/F, Mongkok Exchange, 37 Bute Street, Mong Kok SKG Sai Kung PO G & 1/F, Hermes House, 10 Middle Road TKO Tseung Kwan O PO G/F, 650 Cheung Sha Wan Road Outlying Islands Shops 5 & 6, 1st level, Lai Huen House, Lai Kok Estate CCU Cheung Chau PO G/F, 55 Un Chau Street DBY Discovery Bay PO G/F, 1-2 Fu Shun House, Fu Shan Estate LMA Lamma PO Shop Nos. 111-114, 1/F, Yue Xiu Plaza, 9 Ning Yuen Street MWO Mui Wo PO Shop 1 and Shop 3, 1/F, Enterprise Square, 9 Sheung Yuet Road PCH Peng Chau PO G/F, Kowloon East Govt. Offices Bldg., 12 Lei Yue Mun Road TAO Tai O PO Shop No. 24, G/F, On Kay Court Commercial Centre TCG Tung Chung PO

Personal Particulars of Registrant

HK Permanent Identity Card No. English Name E as shown on the HK Permanent Identity Card I Local Correspondence Address L

C L U K

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8

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6

8

8

(

0

)

Local Contact Telephone No.

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0

1

C H I N

Y U E N

Chinese Name (if applicable)

F L A T 6 0 0 0

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1

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F L O O R R O A D

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H E N N E S S Y C H A I

W A N

Part 2 Cheque Collection Location

HK

/

KLN /

NT

I shall collect the cheque at the post office specified below. P Post Office Code (

G P O

)

Please see overleaf for post office codes and addresses.

Information

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S6K-2(E), page 2 @ Preflight ( 221201541_S6K-2(E).indd.ps, page 1 @ Preflight )