附件四 旅居海外長期居住 就養榮民（註銷）報備聲明書

Declaration Form (Filing for Verification)

聲明人(中/英文姓名)( Name in Chinese/English)	申請人照片 Applicant’s Photo
出生年月日 Date of birth

中華民國身分證或 護照號碼 ID or Passport No.

國外(Overseas)	國名 Country of residence

住址 address

連絡電話 Phone No.
聲明事項 Statements
報備	茲因 （無法）親自返國辦理就養榮民驗證手續，特此報備聲明。 Because of (certain reasons—to be filled in) ( _________________), I am not able to return to Taiwan for the veterans home care verification process, and hereby submit this form as a record. 本人明瞭須依「旅居海外長期居住退除役官兵全部供給制安置就養作業要點」據實陳報全家人口海外所得完成驗證，始不受戶政機關依戶籍法規定為遷出登記應停止安置就養之限制。 I understand that I must abide by the regulation to complete the verification process as requested in “VAC Operation Directions for the Placement of Veterans Home-cared at Full Government-expense”, by enclosing all de facto statements of the total overseas income of mine and my family, otherwise, bound by the regulation, my home-care benefit shall be suspended if my household registration in Taiwan area is removed according to the Household Registration Law.
註 銷報備	茲因 註銷報備，特此報備聲明。 Because of (certain reasons—to be filled in) _______________________________, I hereby request to cancel my previous filing for record of correspondence verification. 本人明瞭並願意接受仍受在臺灣地區無戶籍或經戶政機關依戶籍法規定為遷出登記應停止安置就養之限制，溢領之就養給付應予返還。 I understand and agree to abide by the regulation that my home-care benefit shall be cancelled if my household registration in Taiwan area is removed according to the Household Registration Law, and I will return to VAC all the issued benefit to which I am not entitled accordingly.
以上本人聲明均屬實，如有虛偽造假情事，願負法律責任。 I hereby declare the above statements to be true, and confirm with full legal responsibility for any perjuries found.

授權國內連絡人（姓名、身分證號、地址、連絡電話）：

My liaison in Taiwan (Name、ROC ID number、Address、Contact Phone Number):

____________________________________________________________________

以上事項如有變動，應主動通知榮服處或榮家，否則後果自行負責。(If there are any alterations on the above statements, I should take the initiative to contact the Veterans Service Office or Veterans Home, otherwise I shall be responsible for all the consequences.)

聲明人簽名(Signature)：____________________________(與中華民國身分證或護照相同之中文姓名簽名)(must be signed in the same way as shown on the Passport or ID card)

日期 (Date)：_________________________________________

服務、安養機構名稱：____________________________________

(Name of the competent veterans service office or facility)

…………………………………………………………………………………………

(以下由公證人填寫/For Notary Pubic Only)

I hereby certify that all the contents of this Declaration have been agreed to and signed by _____________________________ in person.

,

(Signature and seal of Notary Public, Date)

註：「親至駐外館處申請驗證」或「先經當地公證程序再送駐外館處驗證」，請依實際需要擇一辦理。（Please choose to apply for verification at the ROC embassies or Overseas Mission where the applicant lives, or to complete the local notarization process as required.）