Application for help. A helping hand when you re in need. Registered Charity number

Transcription

1 Application for help A helping hand when you re in need Registered Charity number

2 Please send the completed form to: Benenden Charitable Trust, Holgate Park Drive, York YO26 4GG Your personal details Title Mr Mrs Miss Ms Other (please specify) Surname Full forenames Address Postcode address Tel no. home Date of birth dd / mm / yyyy Tel no. mobile Tel no. work Gender Male Female Benenden membership number If you are not a member, what connection, if any, do you have with Benenden? How did you hear about Benenden Charitable Trust? Have you applied to Benenden Charitable Trust before? If yes, please give details: Have you applied for help anywhere else for your current need? If so please provide details and the result: We often work with other organisations to get the best result for people asking for our help. These are often associated with a profession or specific employer. Please tell us where you have worked so we can identify additional sources of assistance: To help us assess your financial needs, please give details of everyone else who lives in your household: (please confirm if those aged 19 or under are in full time education) Surname First name Date of Birth Relationship to you Their employment or education status Are they your dependant Y/N Occupant 1 Occupant 2 Occupant 3 Occupant 4 Occupant 5

3 Your household income, savings and investments Please tell us about your household income If you live by yourself, you only need to complete the column marked YOU. If other people live in your home and contribute to the household income, please include their details. If an income type does not apply to your circumstances, please leave blank. Household income: YOU Net income How often do you get this? eg. weekly 4weekly, monthly Your partner Net income How often do you get this? eg. weekly 4weekly, monthly Income from job Income from State Pension Income from occupational/private pension(s) Income from property rental Income from savings and investments State benefits and credits Income Support Pension Credit Employment Support Allowance (ESA) Jobseekers Allowance (JSA) Disability Living Allowance/Personal Independence Payment/Attendance Allowance Carer s Allowance Working/Child Tax Credit Child Benefit Universal Credit Housing Benefit Any other (please specify) e.g. maintenance payments, court order payments, voluntary payments etc. Contribution to household costs from other individuals (please confirm name/relationship) Amount How often do you get this? eg. weekly 4weekly, monthly

4 Please tell us about your savings and/or investments Include details of all savings and investments such as savings accounts, PEPs/ISAs, Premium Bonds, trust funds, stocks and shares and investment property. If you have no savings or investments of any kind, please confirm by entering NIL. Savings YOU Your partner Amount in bank and/or building society (including current account balance). Please state name of Bank and last 4 digits of account number. Value of any other savings/investment held (please state below) Your household outgoings and expenses Please tell us about your living expenses and all of your household expenditure How much do you pay for... Amount How often do you pay this? (eg. monthly, annually) Your home (this can be mortgage, rent, nursing home fees or board and lodging if you live in someone else s home please say which) Heat, light and power Water Council Tax Home and other insurances (do not include car insurance this is covered below) TV, telephone and internet (including mobile phone costs) Groceries Public transport / car expenses (including road tax, car insurance, petrol and maintenance) Prescriptions Childcare costs Other ongoing costs (please state below)

5 Please tell us about any personal debts you or your dependants have Please provide details of any outstanding debts, mortgages, credit card balances or unpaid bills, or if there are arrears with any regular outgoings. Amount In whose name Owed to Type of debt/arrears (Loan/Credit card/bills/arrears) Date payment required Your health To make sure we give you the right help, please tell us about any financial problems which arise in relation to any ill health. It will help us if you can explain exactly what sort of help you would like and an estimate of how much this might cost. We also require medical evidence such as a letter from a GP or consultant giving full details of the current medical situation relating to your application and if applicable, what treatment is now proposed. If you need more space, please continue on a separate sheet and include with your application.

6 Supporting Information IMPORTANT! Please help us to provide you with a quick service by including all required medical and financial documentation. We will not be able to consider your application without it. Before posting your application form, please make sure have enclosed Medical evidence of your condition from your GP or consultant An estimate of the cost of any treatment service or equipment you require A statement of exactly what help you would like Benenden Charitable Trust to consider providing A copy of the most recent account statement for all bank/building society and investment accounts relating to yourself and your dependants, covering at least one full, recent calendar month Your declaration and signature Data Protection We will treat any personal information you give us confidentially. We will record relevant data to our database. We never give your personal details to anyone else for their marketing purposes. I agree that all details provided in this application can be passed to other charitable or similar organisations which may also be able to help. I declare that the information given is true and complete to my best knowledge and belief. I confirm that all individuals have consented for their financial details and documents to be shared with this application. To consider your application fully we may need to refer to your Benenden medical and membership records. By submitting this application you consent to Benenden Charitable Trust receiving or viewing your health records in this way. If you would like help completing the form Signature Date dd / mm / yyyy If the applicant is unable to sign this form, or you are applying on someone else s behalf (and you do not live with them) please call us on * to discuss the supporting information we * charitabletrust@benenden.co.uk *Please note that your call may be recorded for our mutual security and also for training and quality purposes. Benenden Charitable Trust is a company limited by guarantee. Registered in England and Wales, number Registered charity number Registered office, Holgate Park Drive, York, YO26 4GG APP/CHARITABLE/SP8752/07.15/V1