The National Benevolent Charity. Application Form

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1 The National Benevolent Charity Application Form The National Benevolent Charity was founded in 1812 by Peter Hervé to give pensions and allowances to the poor and distressed. Over 200 years later the Charity continues to give financial help to people who have fallen onto hard times, through no fault of their own, and who need a helping hand. Financial help can be in the form of a single payment to meet particular needs or items of expenditure, such as the cost of replacing broken appliances, urgent house repairs, replacing furniture or clothing, etc., or weekly payments for a limited period to supplement state benefits. All applications are considered by the Charity s Welfare Committee, which meets every two or three months. Urgent applications can sometimes be considered, but only in exceptional circumstances. Eligibility To be eligible for assistance, an applicant must have been resident in the UK for the last 24 months, and be unable to work because of age, sickness, disability or for some other substantial reason, and must be able to show serious financial need. The Charity aims to be flexible and to take all factors into account. However, as a guide, a single person applying for a weekly payment should normally have income, after housing costs have been paid, of less than 8,000 per annum, and a couple income of less than 12,000 per annum. Higher levels of income are allowed in the case of applications for single payments. All income, including that from disability benefits, is taken into account. The Charity expects applicants to be in receipt of all state benefits to which they may be entitled, and it also expects applicants to have applied for assistance to any benevolence charities with which they may have a professional or industrial link. For example, a nurse should have first applied to the several benevolence charities founded to support nurses in need, and a civil servant should first have applied to the Charity for Civil Servants etc. It is also expected that applicants will have first considered options such as approaching other members of the family, particularly working sons and daughters, and taking advantage of equity release schemes. However, it is important to appreciate that Charity s funds are very limited and that meeting the eligibility criteria is no guarantee that any grant or payment can be made.

2 Applicants who are in significant debt will not be assisted unless their debts are being managed with help from a reputable, and preferably charitable, advice agency such as the Citizens Advice Bureau or the Money Advice Trust. The Charity will not, other than in the most exceptional of circumstances assist with the repayment of debt. Neither will the Charity make payments to substitute for state welfare benefits that have been withdrawn, or to repay state welfare benefits that have been wrongly claimed. Completing the Application Form Applicants are welcome to complete the form themselves and to submit it to the Charity. However, it may be helpful for a third party, such as a health or social worker, CAB worker, welfare rights advisor or other independent person to assist the applicant in completing the form and to vouch for the applicant and the accuracy of the information. All sections of the form must be completed and applicants should provide as much relevant information as possible. The more that the Charity knows about the applicant and his or her circumstances, the more likely it will be that a speedy decision will be made. Where illness or disability is the reason for the application, medical evidence may be requested. The name and address of a doctor or other health professional treating the patient who would be willing and able to confirm the diagnosis or condition should be included. Applicants who need help or advice about completion of the form can contact the Charity by telephone or . The Charity is registered with the Information Commissioner and is fully compliant with all data protection legislation. In order to deal with applications for financial support, the Charity needs to collect and retain information about applicants, and sometimes to share this information with other charities. A data collection and retention consent form is appended to the application form and must be signed and returned with the application form. Co-operation with other Charities Applicants should be aware that the Charity co-operates and works closely with other benevolence charities to ensure that there is no duplication and that any financial assistance is within the limits set by the trustees of each charity. Information about an application may therefore be shared with other charities in the field.

3 The National Benevolent Charity Application Form PLEASE PRINT. ALL SECTIONS MUST BE COMPLETED. Full Name Title Born / / 19 Address Years at this address Previous Addresses in last 10 years with dates Telephone home mobile address Marital status Single / Married or Cohabiting / Separated / Divorced / Widowed Name of spouse/partner occupation Education and Qualifications (please give all dates)

4 Occupations and work, including voluntary work since leaving school (please gives all dates) Other family members, including sons and daughters living away (please continue on a separate sheet if necessary). Name Address Age Occupation Name Address Age Occupation Name Address Age Occupation Name Address Age Occupation Relationship Relationship Relationship Relationship

5 Please explain what help you are seeking and the reasons for your application, setting out all relevant circumstances such as any illnesses or disabilities, financial misfortune, special commitments or needs etc. Please continue on a separate sheet, if necessary.

6 What other charities have you applied to and what response, if any, have you received? Please note that the Charity expects applicants to have applied to any trade or professional benevolent funds for which they may qualify. Information about all benevolence charities may be obtained from the organisation Turn2Us, see website or telephone free helpline How did you find out about The National Benevolent Charity? Are you in receipt of all state benefits to which you are entitled? Yes / No / Not Sure Please note that Charity will not be able to help unless you are claiming all state benefits to which you are entitled. This will include grants for disability adaptations. Advice about benefits may be sought from a benefits advice service or from the Citizens Advice Bureau. Please give the names, addresses and telephone numbers of two referees we can contact for confirmation of the details of your application. A referee may be an advice or welfare worker, your doctor or district nurse, or someone who has known you for a number of years. However, some GPs make charges for writing letters and it is not expected that you should incur any costs. A referee should not normally be a relative. Referee 1. Referee 2.

7 INCOME PER WEEK Benefit or Payment amount state pension widow s pension pension credit personal pensions occupational pensions attendance allowance higher rate lower rate DLA or PIP care/ daily living component enhanced rate standard rate mobility component enhanced rate standard rate carer s allowance incapacity benefit, JSA or ESA income support tax credits child benefit any other welfare benefit housing benefit council tax support payments of alimony payments from other charities name of charity name of charity investment income or savings interest any other income or payment Total Income Income of any other person, or persons, in your household. name of person Relationship to you income

8 EXPENDITURE PER WEEK Type of expenditure amount rent mortgage payments: state number of years remaining: years ground rent and service charges house and contents insurances life, endowment and other insurances council tax water and sewage charges loan repayments: electricity charges: gas charges: other fuel costs telephone carer, home help and related services MOTORING AND/OR TRANSPORT COSTS Please state the name, model and registration number of any vehicle in the household, & whether it is adapted for disabled use, and also the details of regular bus, train and taxi journeys. Vehicle Other transport cost per annum cost per annum ASSETS AND DEBTS (if none, please write none) balance in current bank accounts.... deposit accounts, including building society accounts any other savings.... investments, including PEPs, ISAs and shareholdings.... mortgage outstanding.... outstanding loans to banks, credit card companies etc.... any other debts or liabilities....

9 Please note that the Charity will wish to see supporting documents to confirm the details of your application. These documents may include copies bank statements, benefits statements, rent or mortgage statements, utility bills etc. These documents should NOT be sent at this time. Declaration: I hereby declare that the information provided in this application is true and accurate to the best of my knowledge, and I authorise the Charity to contact my referees and to discuss my application with other charities and agencies on my behalf. Signed... Date... The National Benevolent Charity Peter Hervé House Eccles Court Tetbury Gloucestershire GL8 8EH Telephone Website Royal Charter Number: RC Charity Number:

10 Bank Details It is the practice of the Charity to make any payments directly into a bank account. Please provide your bank details. bank or building society name... address account holder s name... sort code...account number... building society reference (if applicable)...

11 Data Protection Consent Form If you, or someone on your behalf, completes the Application Form an electronic and/or paper file will be opened for you which will contain the information in the Application Form and any subsequent correspondence with you, your doctors, referees, others such as advice workers and social workers and public authorities. The file(s) will also contain the reports of any visits made to you and details of financial payments made to you. The files will be kept securely and in strict confidence and will not be passed to any other individual or organisation without your consent, except where required to do so by law or as explained in the next paragraph. Information in your file(s) may be shared with other charities to whom you have applied for help, or to whom you might apply, and to charities which are currently providing you with support or which have supported you in the past. Information may also be shared with your referees and with any of your advisers and supporters named in the application. You have the right to request a copy of your file(s) except for any information held within them about another person. A charge of 5 will be made for a copy. Your file(s) will be destroyed six years after you last receive support. Declaration: I have read and understand the above and I agree to The National Benevolent Charity maintaining file(s) with information about me and sharing that information with other charities in the circumstances set out above....signed...date

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