Welfare Fund Application Form

Welfare Fund Application Form
Applicant Name: *

Title Forename Surname
Is the applicant? *

Male Female
Date of Birth: *

Day Month Year
Has the applicant applied to the National Benevolent Charity before? *

Yes No
Approximate date of application: *
What was the outcome? *
Current Address: *

Address 1

Address 2

Town / City

Postcode
Applicants Email: *

Confirmation Email
Tel: *
Mobile: *

Who should we contact about this application? (If other, please give details below) *

Referrer Applicant Other
Contacts Name: *

Forename Surname
Relationship to applicant: *
Contacts Email: *

Confirmation Email
Tel: *

Total in the household: *

Names of other adults in household

Ages of other adults in the household

Names of children in household

Ages of children in the household

What is the application for? *
Estimated total cost of request? *
Has the applicant applied to other charities? *

Yes No
Other application details?
What was the outcome?
How did the applicant hear about The National Benevolent Charity? *

Estimated Income of the whole household *

per month

Bring Home Pay (applicant)

(spouse/partner/adult(s) in household)

State/Private/ Occupational Pension

Pension Credit, Working/ Child Tax Credits

Universal Credit

Jobseekers Allowance

ESA

DLA/PIP/Mobility Allowance

Carer's / Attendance Allowance

Child Benefit

Family &/or Lodger Contributions

Child Maintenance

Other

Total

Estimated outgoings of the whole household *

per month

Mortgage (applicant)

Rent (after Housing Benefit, if received)

Council Tax (after Council Tax Support)

Gas, Electric & Water

Housekeeping (e.g. food, supermarket shop)

Help at Home (e.g. cleaner/gardener)

Landline, Mobile & Broadband

Car/Transport (e.g. fuel, insurance, tax etc.)

Other insurances (e.g. life, household etc.)

Loans/Debt Repayments

Childcare Costs

Other

Total

Household Savings *

Please include total of bank and building society accounts and the value of premium bonds, stocks & shares,ISAs etc.

Applicant savings

Spouse/Partner savings

Other adult(s) in the household

Does the applicant (or anyone in the household) own property other than the house in which they live? *

Yes No

Background to this application
Please confirm what is being requested and how it will contribute to the welfare of the applicant. List needs in priority order. *

0/300
Employment
If the applicant and/or their spouse/partner is not in paid employment, please tell us what is preventing them? *
Is the applicant professionally trained, for example as an accountant, teacher, musician, nurse, banker etc.? *
Does the applicant have a referrer? *

Yes No
For Referrers
Describe the applicant situation and clinical diagnosis (where applicable) *

0/300
How long have you/your organisation known the applicant? *
When did you last see the applicant? *
Organisation: *
Job title: *
Referrer Name: *

Forename Surname
Postal Address: *

Address

Address Line 2

City

Postcode
Referrer Email: *

Confirmation Email
Referrer Phone: *

Please give your bank details for payment if you are successful *

Name on bank account

Name of bank

Sortcode

Account number

Consent
I consent to the sharing of information relevant to this application with my referrer and/or any other contact listed on this application and any supplier of the charity connected with the fulfillment of any award. *

Yes No
I consent to being contacted the National Benevolent Charity to share feedback on my experience. *

Yes No
Statement by signing this form, I confirm that I have given a true picture of my circumstances.
Signature of applicant: *

Clear
Date

Day Month Year
Please submit this completed form together with your most recent monthly bank statement and medical evidence (if applicable). *

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Cancel of
You must use different email addresses for the applicant and where specified the referrer or other contact
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