Grant Application Form - Handsworth Charity

Sponsoring Organisation Details

Name of Person Referring*

Organisation Name*

Organisation Address*

Street Address Address Line 2 City Post Code

Telephone Number*

Organisation Email*

Applicant Details

Title*

Mr.

Mrs.

Miss.

Ms.

Other

Name*

First Last

Address*

Street Address Address Line 2 City Post Code

Email*

Telephone Number*

Date of Birth*

Please indicate your status*

Single

Married

Widowed

Divorced

Other

Number of Dependents (with ages):*

Name

Age

CONFIDENTIAL

You may be eligible for a one-off grant, therefore please complete the following:-

I apply for a single payment grant of £*

For the following purposes (please give details and a quotation if possible)*

List other people living in Household that are not dependent (age 19+):*

Against each person please indicate if employed/unemployed or in full time education.

How long have you lived at your present address?*

Are you in employment?*

Full Time

Part Time

Unemployed

Do you own the property in which you live?*

Yes

Please state tenure of property:*

Do you sub-let part of your home?*

Yes

What income do you receive from sub-letting your home?*

What sort of building do you live in?*

Do you have any illness or disability that prevents you from maintaining yourself and your dependents?*

Yes

Please provide details*

Is it sheltered housing?*

Yes

Do you have a bank account?*

Yes

If no, if you are given a grant in whose name should the cheque be made out?*

If you have any other special circumstances of which you wish the Trustees to be aware, please mention them below:-*

Have you received support from Handsworth Charity in the past?*

Yes

If so, please state approximate date and what for*

Have you approached or received support to help with your request from another charity?*

Yes

Please state details of previous or current support from other sources:*

FINANCIAL CIRCUMSTANCES

Please give the following details of your weekly or monthly income and outgoings for every question. If none, please say so. (Attempt to give an estimate if you are uncertain of the exact amounts.)

Incomings*

Outgoing*

Salary/Wages*

Contributions from others*

Rent or Mortgage*

Contributions from others*

Benefits*

Contributions from others*

Council Tax*

Contributions from others*

Income Support*

Contributions from others*

Water Rates*

Contributions from others*

Job Seekers Allowance*

Contributions from others*

Gas*

Contributions from others*

Housing Benefit*

Contributions from others*

Electricity*

Contributions from others*

Disability/Living Allowance*

Contributions from others*

TV Rental and/or Licence*

Contributions from others*

Attendance Allowance*

Contributions from others*

Insurance(s)*

Contributions from others*

Child Benefit*

Contributions from others*

Loan Repayments*

Contributions from others*

Maintenance*

Contributions from others*

Credit Card/Bank Overdraft*

Contributions from others*

Retirement Pension*

Contributions from others*

Debt Repayments*

Contributions from others*

Superannuation/Work Pension*

Contributions from others*

Travel Expenses*

Contributions from others*

Other Awards/Grants*

Contributions from others*

Telephone Costs*

Contributions from others*

Payment from lodger*

Contributions from others*

Childcare*

Contributions from others*

Other Income*

Contributions from others*

Other Expenses*

Contributions from others*

Total Incomings*

Total Outgoings*

Declaration

To the best of my knowledge, the answers provided on this form are true. I understand that the completion of this form does not necessarily mean I will be offered grant support. I understand that I must inform Handsworth Charity of any changes in my circumstances while my application is being considered.

To be completed by the Applicant:

To the best of my knowledge the above details are a true description of my circumstances.

Signed*

Date*

Consent*

I agree to the privacy policy.

Information and Advice Consent

Permission has been received from the applicant in writing to provide the necessary information to complete the application form. A copy of the consent form is attached and details of how the personal data and information is stored and processed as required by the Data Protection Act 2018.

If the application is successful, I confirm that the organisation will administer the grant on behalf of the applicant and ensure that a report on the purpose it was given for is provided.

To be completed by the Sponsoring Organisation:

I have read and understood these details

Signed*

Date*