MINISTRY OF HEALTH
APPLICATION FOR INSTITUTION OF A PUBLIC CHARACTER STATUS
To:
Membership Branch
Community Partnership & Development Division
Ministry of Health, HQ
College of Medicine Building
16 College Road
Singapore 169854
FORM 4
INSTRUTIONS
(i)
Please complete this application form and submit it to MOH together with:
The organisation’s governing instrument (a copy of the constitution or the
Memorandum & Articles of Association )
The latest audited set of Financial Statements and Annual Report
Descriptions of the organisation’s services and programmes
IPC Form 6/7 (for Renewal applications only)




(ii)
(iii)
(iv)
This application must be signed by the President/Chairman/CEO or Honorary General
Secretary of the Organisation and must be accompanied by a covering letter addressed to
MOH.
New applications for IPC status must be submitted to the Ministry at least 2 months in
advance.
Renewal applications must be submitted to the Ministry at least 2 months before the expiry
of the current IPC status.
PART A TYPE OF IPC STATUS
(Please tick  where applicable)
New
 General
 Specific
Renewal
 General
IPC Reference No: ___________________
Duration granted: ____ yr(s) From _____________ to _____________
 Specific
IPC Reference No: ___________________
Duration granted: ____ yr(s) From _____________ to _____________
Amount approved to fund-raise: _______________________________
Has your organisation been granted IPC status previously? Yes No
If yes, please specify Reference No. _______________________
Has your organisation applied to any other umbrella bodies for tax-deductible status?
Yes No
If yes, please specify:
i) name of the Fund: _________________________________
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ii) date of application made: _________________________________
iii) outcome of application: accepted  rejected  awaiting outcome
PART B PARTICULARS OF ORGANISATION
1.
Name of Organisation
:______________________________
2.
Address of Organisation
:______________________________
3.
Telephone No.
:______________________________
4.
Fax No.
:______________________________
5.
Email Address / Website
:______________________________
6.
Name of Head of Organisation
:______________________________
Designation of Head of Organisation
:______________________________
7.
Particulars of liaison officer:
Name of Liasion officer* (in full) __________________________________________
NRIC No: ____________________
Email Address: __________________________
Address:
______________________________________________________________
Contact No. _____________ (O) ___________________ (H) _______________(H/P)
Occupation:
___________________________________________________________
Name of Employer: _____________________________________________________
Address of Employment _________________________________________________
Position in organisation: _________________________________________________
*Liasion Officer is usually the key administrative officer such as General Manager, Chief
Executive who will be held accountable for management of funds in the Special Account.
8.
Date & Number of Registration with
:______________________________
Registry of Societies under the Societies Act or
Registry of Business under the Business Registration Act or incorporated under the
Companies Act
9.
Date of Registration with Commissioner
Of Charities and Registration No.
:______________________________
10.
Commencement and end of financial year
:______________________________
11.
How many centres does your organisation
have?
:______________________________
Total current staff strength
(include all full and part-time)
:_Local:_________Foreign:_________
12.
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13.
Total current volunteers strength
:______________________________
14.
No. of beneficiaries (per year)
:______________________________
Nature of Organisation (List mission and objectives of organisation)
_________________________________________________________________________________
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



Private Hospital
Healthcare Organisation
Step-down care Services, please specify service type :___________________
Restructured Hospital
Others, please specify:
_______________________________________________________________
PART C KEY MANAGEMENT COMMITTEE MEMBERS
14.
List of all Management Committee Members. (Please use separate sheet if space is
insufficient).
Nationality
Occupation and
Relationship to
Name
& NRIC
Designation
Name of
Committee Members
Company/Employer
(if any)
PART D ACTIVITIES/PROGRAMMES
15.
Briefly describe activities/programmes run by your organisation. (Please use separate sheet if
space is insufficient).
Annual
Annual
Targeted
Name of Programme/Activities with brief
No of
Income
Expdt
Audience
description
Staff
Type1
No.
16.
Briefly describe any specific funds set for specific projects (e.g. a building fund, an
anniversary fund or an endowment fund.) (Please use separate sheet if space is insufficient).
_________________________________________________________________________________
1
Elderly Sick, Children etc
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PART E DONATIONS
17.
Estimated annual donations projected to be collected in next 3 years (for both new and
renewal application)
Amount
S$
Current Financial Year:
eg 2004
Eg. $X+$Y+$Z
1.
1
2
3
Programmes planned to raise
donations
.$X
$Y
$Z
$X+$Y+$Z
Next Financial Year:
eg 2005
Subsequent Financial
Year: eg 2006
Total:
18.
Actual amount of donations received in the last 3 years of operation (For Renewal
Applications only)
Amount (S$)
Previous
Financial
year:
Eg. Year 2003 (audited)
Eg. $X+$Y+$Z
2.
Briefly describe sources of prominent
donations
1. $Y
2. $Z
3. $Z
$X+$Y+$Z
Financial year before
last:
eg Year 2002 (audited)
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Subsequent Financial
year before last: eg
Year 2001 (audited)
Total:
PART F EXPENDITURE
19.
Estimated annual expenditure projected for next 3 years (for both new and renewal
application)
Amount
(S$)
Current Financial Year:
eg 2004
Eg. $X+$Y+$Z
Briefly describe broad categories of
expenditure
(eg. Advertisements, printing of tickets,
posters rental, cost of setting up of stalls,
staff costs, utilities, etc).
1.
2.
3.
Next Financial Year:
eg 2005
Subsequent Financial
Year: eg 2006
Total:
20.
only)
Actual amount of expenditure in the last 3 years of operation (For Renewal Applications
Amount
S$
Previous Financial year
eg.
Year
2003
(audited)
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Eg. $X+$Y+$Z
Briefly describe broad categories of
expenditure
1.
2.
3.
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Financial year before
last:
eg Year 2002 (audited)
Subsequent Financial
year before last eg
Year 2001 (audited)
Total:
PART G ADDITIONAL DETAILS ON DONATIONS & FUND RAISING EXPENSES (LATEST FY)
Please state FY: ____________
(A) Donations in cash from individuals
Non-tax exempt ($)
Tax exempt ($)
(B) Donations in cash from Corporations, Institutions &
Foundations
(C) Donations in Kind
(D) Sponsorships2
(E) Total Donations and Sponsorships (A + B + C + D)
(F) Direct fund raising expenses3
(G) Sponsorships
(H) Indirect/Allocated costs 4
(I) Total fund-raising expenditure (F + D + G)
(J) Fund raising Efficiency Ratio before sponsorship (HD)/(E-D)
(K) Fund raising Efficiency Ratio with sponsorship (H/E)
PART H ADDITIONAL INFORMATION FOR IPC STATUS (SPECIFIC) APPLICATON ONLY
21.
Name of Project / Programme:
22.
Brief description of project for which fund is to be established. (Please use separate sheet if
space is insufficient).
______________________________________________________________________
______________________________________________________________________
2
The value of in-kind support received (eg. prizes used in a charity auction, cost of a sponsored fund-raising
dinner) and which are used in the fund raising exercise.
3 Costs directly incurred and paid for ion the fund-raising exercise. They include such costs as advertisements,
prizes, printing, publicity materials, rental of premises, logistics etc.
4 Costs of personnel and administrative/marketing overheads of the organization used to support the fundraising.
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23.
Please provide details of budgeting plan for project:
Dollars
Total amount required for entire project
(please attach details/break down of items & costing)
Amount of approved government funding (if applicable)
Amount to be raised
24.
Expected completion date of project
: ______________________________
25.
Duration required to collect the total amount needed: _____________________________
26.
Have you applied to MOH for any other project funds within the past 5 years?
 Yes (please specify)
__________________________________________________________
 No
27.
Where the specific membership pertains to a Building Fund, the applicant must show proof of
an established need for acquiring the building e.g. relevant governmental documents. The
relevant documents must be submitted to MOH together with this application form.
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PART I DECLARATION
I agree to abide by the Charities Act and all the Regulations promulgated for the IPC status.
I also certify that the information given in this application is, true and complete.
______________________
Name of Applicant
________________________
Signature
______________________
Designation in Organisation
_________________________
Contact No.
=============================================================================
PARTJ OFFICAL USE ONLY
Date application received:
____________________
 Approved
 Rejected
IPC Status (General)
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Supported for 1 year
Supported for 2 year
Supported for 3 year
Not Supported / KIV
IPC Status (Specific)
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Supported for _______ year(s); to fund-raise $ ________________
Not Supported / KIV
Other comments: ______________________________________________________________
_____________________________________________________________________________
Approved Registration No:
____________________
Date Approved:
____________________
IPC Status period from _________________ to __________________.
____________________________
(Processed by)
_______________________________
(Date)
* Tick where applicable
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