"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:
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
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:
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