Application Form

INDIVIDUAL – APPLICATION FORM
PLEASE READ THE GUIDELINES BEFORE COMPLETING THIS FORM AS ANY INCOMPLETE FORMS WILL BE REJECTED

 Applicant’s Address:

Applicant’s Post Code:

Telephone No.:

Gender:

What is the application for?:

Where did you hear about us?:


About the applicant’s address (please select one):
Is it privately owned by resident:
Is it rented from private landlord:
It is social housing:
Is resident(s) living with friends/family:
Other:

Please list all members of the family who live at the same address:


Name
DOB
Occupation School

Applicant:
Partner:
Child 1:
Child 2:
Child 3:
Child 4:

Is applicant a refugee:

Refugee status:


Report: Please read the attached Guidelines before completing this section. Use a continuation sheet if necassary.
Applicant’s Medical Conition(s), please answer specific questions below and include all relevant details about the applicant’s current medical conditions:

Details of medical condition and impact on their life:

Is it likely that the applicant will be able to work?:

If so, please give date of return to work here:

Background/Brief History of Applicant:

Current Circumstances:

Help requested: (if request is for a specific item or a piece of medical equipment, please ensure the full
costs and any contributions already secured are included here).

The Impact This Will Have:

Wider Support in Place:

Your Organisation/Role:


Family or Individuals’ Finances Form
PLEASE MAKE SURE THAT THIS SECTION IS COMPLETED ACCURATELY AS TRUSTEES REVIEW THIS AS PART OF THEIR DECISION-MAKING PROCESS.

 The figures below must be based on the monthly income and expenditure and contain totals. If this is not completed correctly then the application will be rejected. Any surplus in funds requires an explanation.

Family’s household finances
Income (£)
Expenditure (£)

Net Salary: Rent/Mortgage:
Partner’s Net Salary: Ground Rent/Service Charge:
Maintenance – Child Support: Council Tax:
Universal Credit: House Insurance:
Housing Benefit: Water Rates:
Council Tax Benefit: Gas:
Income Support: Electricity:
Employment & Support Allowance: Home/Mobile Phones:
Working Tax Credit: TV Licence (inc. cables):
Child Tax Credit: Internet:
Child Benefit: Food & Household:
DLA/PIP (Mobility): Car costs – for each vehicle:
DLA (Care) PIP Daily Living: Transport Costs:
Carers Allowance: Hire Purchase Repayments:
Attendance Allowance: Catalogue/Club Repayments:
State Retirement Pension: Bank Loan & Overdrafts:
Pension Credit: Credit & Store Card Repayments:
Other: Debts – Monthly Amounts
Rent/Mortgage:
Council Tax:

Water:

Telephones:

Electricity:

Gas:

HP Repayments:

Social Fund Loan:

Other:


Total Income: Total Expenditure:

Has the family had a recent welfare benefits check?:

Debts
Total Outstanding

Rent/Mortgage:
Council Tax:
Water:
Telephones:
Electricity:
Gas:
HP Repayments:
Social Fund Loan:
Other:

Total Debt:

Details of other applications for these items
(E.g. application to any other statutory or charitable organisations, etc. Specify amount requested and outcome)
1:

2:

3:


Declaration:
To the best of my knowledge the information provided in this application is correct and I agree to keep the terms and conditions outlined in the guidelines should any aid be provided. I understand that the completion DOES NOT guarantee that any funding will necessarily be approved. I also agree to contact the Secretary to the Trustees concerning ANY changes to the details provided on this form.

Support Worker’s Contact Details

First Name:

Last Name:



Organisation:

Your Role/Job Title:

How long have you known the applicant?:

Address:

Telephone No.:

Signature:

Date:


Supporting Documents File Name: