Statement of Facts

[신청서] 2025 영유아 건강권 지원사업 신청서

2026 영유아 건강권 지원사업_사실확인서(영문)

Child (0~7 years old)	Name		Gender	Nationality/ Visa status		Birthdate (yy.mm.dd)		Place of Birth			Date of Entry to Korea
			□ M □ F			( years old)
	Address
Guardian	Relation	Name			Nationally/ Visa status		Birthdate (yy.mm.dd)		Contact No.	Date of Entry to Korea

※ Additional documents required for organization applications: Statement of Facts, Business Registration Certificate.

This is to confirm that the economic situation of the above infant/toddler's guardian is as follows.

1. Wage Income

(average of the 3 months prior to the application date; combined income of guardian(s))

Example) January 2026, part-time construction work (daily wage: 00 won, working hours: 0 hrs/day): 2,000,000 won/month

2. Emergency Livelihood Support Checklist

Category	Item	Applicable
Economic Urgency / Need for Livelihood Support, etc.	Health insurance premium in arrears
	Unpaid utility bills
	Unemployed due to accompanying child for medical treatment
	Difficulty maintaining livelihood due to multiple debts
Social Vulnerability	Single-parent family, illness/disability of a family member, household head is a minor, multiple children (2 or more)

3. Need for Emergency Livelihood Support

(If any checklist item applies, please describe the details specifically)

Details

2026     mm    dd

Applicant Organization :                      (seal)

Applicant (□ Father □ Mother) :                           (signature)