"Indemnity Form for Refund" - Singapore

This "Indemnity Form for Refund" is a document issued by the Singapore National Environment Agency specifically for Singapore residents with its latest version released on September 13, 2013.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Singapore National Environment Agency.

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National Environment Agency

FOR OFFICIAL USE

Hawker Centres Division

HDB Hub

Received & Checked

Counterchecked by:

by: CCC

TS Officer

East Wing #26-01

480 Lorong 6 Toa Payoh

Singapore 310480

Date:

INDEMNITY FORM FOR REFUND

In consideration of the National Environment Agency paying to me the sum of Dollars

_____________________________________________ only ($_______________) being the

amount payable to the late ___________________________________________ in respect of

stall No. #_____ - ________ Block ___________________________________________.

I, _______________________________________ NRIC No. ___________________

of __________________________________________________ being ___________________

(relationship) of the late ____________________________________ hereby for myself, my

heirs, executors or administrators, indemnify the said National Environment Agency against all

actions, proceedings, suits, claims and demands, moneys, losses, damages, costs and

expenses which may be brought against, or be paid, incurred, sustained or taken by the said

National Environment Agency in respect of, relating to or arising out of the paying to me of the

amount specified above.

Dated this ______ day of ____________________ 20_____.

Signed by the said : _______________________)

_______________________)

_______________________) ________________________________

Signature/RTP

In the presence of:

Name of NEA Staff : ______________________)

Designation

: ______________________)

________________________________

Signature

The National Environment Agency (NEA) collects personal information to carry out its various functions and duties under the National Environment

Agency Act (Cap 195) including the implementation of environmental and public health policies in Singapore and any other related purposes. I hereby

consent to NEA’s use of the information provided by me in the course of any application I have made to the NEA, to facilitate the processing of such

application for such purposes. I hereby further consent to NEA sharing the information in such application with other Government agencies, or non-

government entities authorised to carry out specific government services, unless prohibited by legislation.

HCD/IND/Ref: 13 Sep 2013