急難慰助金申� �表.pdf

WuFeng University of Science and Technology Emergency Assistance Application Form
Application Date: Year Month Day
Department
□Day Department □Continuing Education Night Class
□Continuing Education Holiday Class
System
□Two-Year Technical □Two-Year Specialized
□Four-Year Technical
Class
Student ID
Name
ID Number
Mobile Phone
Parent's Name
Contact Phone
Address
I. Reason for Emergency (Student's Statement): Time, Place, and Description of Events
II. Attached Documents (Please list in order): Check the boxes with a "V"
(1) □Household Registration Transcript (within 3 months)
(2) □Student ID Card (front and back, with semester registration stamp and personal seal)
(3) □Low-Income Household Certificate (with proof from local government)
※Other relevant proof documents:
(4) □Medical Diagnosis Certificate
(5) □Death Certificate
(6) □Counselor Interview Record
(7) □Other:
Instructor's Opinion
(Signature)
Department Head's Opinion
(Signature)
The following is to be filled out by the Student Assistance Division staff
III. Emergency Assistance Application Conditions and Standards:
(1) □Student hospitalized for accidental injury or major illness for 3 days or more: NT$2,000 subsidy
(Additional NT$2,000 subsidy for low-income households certified by the government)
(2) □Student hospitalized for accidental injury or major illness for 7 days or more: NT$6,000 subsidy
(Additional NT$2,000 subsidy for low-income households certified by the government)
(3) □Student suffering from major illness: NT$5,000 subsidy
(Additional NT$2,000 subsidy for low-income households certified by the government)
(4) □Student's accidental death: NT$10,000 subsidy
(5) □Student's parent's death: NT$7,000 subsidy
(6) □Student's parents' death: NT$10,000 subsidy
(7) □Severe property loss: NT$5,000 subsidy
(8) □Student experiencing sudden financial difficulties due to family circumstances: NT$6,000 subsidy
(Requires low-income household certificate, poverty certificate, or counselor's visit record)
Student Assistance Division Staff
Student Assistance Division Director
Student Affairs Director
Accounting Office
Remarks
1. Students must apply within 3 months of the incident (late applications will not be accepted).
2. Students can only apply for assistance once for the same incident during their time at the school.
3. This application form and attached documents must be signed by the instructor and department head before submission to the Student Assistance Division.