COTTENHAM CHARITIES GRANT APPLICATION

COTTENHAM CHARITIES
APPLICATION FOR A GRANT:
The information contained in this application form is provided to the charity in confidence and will not be disclosed to anyone other than the Secretary and Trustees.

Applicants are advised that failure to dislcose any relevant information may prejudice their application. Misleading or inaccurate informaton may lead to your application being refused.
YOUR Name*

First NameLast Name
YOUR Date of Birth*

MonthDayYear
Enter your date of birth
Your Occupation
Your Partner's Name

Parner's First NamePartner's Last Name
Partner's Date of Birth

DayMonthYear
Enter your partner's date of birth
Partner's Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
Email
example@example.com
Phone Number*
Please enter a valid phone number.
How long have you lived at the above address?*
Please state the number of years you have lived at the address given
Please give the name and age of children aged 16 or under
Child 1 Name
Child 1 Age
Child 2 Name
Child 2 Age
Child 3 Name
Child 3 Age
Child 4 Name
Child 4 Age
I receive the following benefits*

Universal CreditHousing BenefitCouncil Tax Support (not single occupancy discount)Employment and Support Allowance - Work RelatedEmployment and Support Allowance - Support GroupPension CreditPension Savings CreditIncome SupportIncapacity Benefit (with no other income)
REASON FOR APPLICATION Please give details of why you need financial assistance and of any disabilities you may have*
Give details of why you need financial assistance
The charity prefers to pay directly to the providers of goods so please list what you would like to purchase and the estimated price. We often recommend the British Heart Foundation for electrical goods and Emmaus or Cambridge Re use for furniture but other sources will be considered. PLEASE LIST ITEMS YOU REQUIRE WITH AN ESTIMATE OF COST*
Please give details of the items you require and an estimate of cost
Signed *
Simply type your full name
Date*

DayMonthYear
A Trustee will visit you after you return this form to discuss your needs and assess your financial situation.
Should be Empty:

COTTENHAM CHARITIES

APPLICATION FOR A GRANT: