RISE Grant Application

Applicant Name:*

TitleForenameSurname

Current Address:*

Address 1

Address 2

Town / City

Postcode

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

ReferrerApplicantOther

Applicants Email:*

Confirmation Email

Date of Birth:*

Mobile:*

Tel:*

Is the applicant?*

MaleFemaleOther

Contacts Name:*

ForenameSurname

Relationship to applicant:*

Contacts Email:*

Confirmation Email

Tel:*

Total in the household:*

	Names of adults in household	Ages of adults in the household	Names of children in household	Ages of children in the household
1.
2.
3.
4.
5.

Grant Details

What do you need the grant for?*

Please tell us about your circumstances and confirm what you are applying for and why.*

0/300

Estimated total cost of request?*

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 Income

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 Outgoings

Please give the name and contact details of your referrer.

Applications that do not have a correctly completed referrer section will be rejected.

Organisation:*

Job title:*

Referrer Name:*

ForenameSurname

Postal Address:*

Address

Address Line 2

City

Postcode

Referrer Email:*

Confirmation Email

Referrer Phone:*

For Referrers

Please supply a description of the applicants current circumstances, what they are applying for, how they are professionally involved with you and clinical diagnosis (where applicable). *

0/300

How long have you/your organisation known the applicant?*

Preferred Method of Payment

If successful which is your preferred method of payment*

Direct to bank accountVouchers which can be redeemed online or in person at Currys, John Lewis or Argos and all supermarkets including Lidl and AldiPaid to supplier/contractor direct (suitable for flooring, utility bills, rent arrears etc)Cash from ATM (emergency use only - maximum £500)

Please provide the applicants bank details for payment direct to applicant bank account (supplier bank details will be collected separately)*


Name on bank account
Name of bank
Sortcode
Account number

Bank Statements

To assess the application, we will need to see a bank statement belonging to the applicant which is no more than two months old.

Ideally, the applicant will use the link below to connect to their bank account. This will take the applicant through to our partner site Lightning Reach. After they have connected to their bank account, they will receive an email from Lightning Reach with a code startng with "IND". They must return to this site to submit their application, including the Lightning Reach.

Alternatively, the applicant can attach the bank statement as a pdf or photo below. Please note multiple screenshots are not acceptable and will be rejected.

I would like to provide my bank statement by connecting to my account*

YesNo

if you choose "No" you will need to attach a bank statement (not more than 2 months old) belonging to the applicant

You have chosen to connect your bank account, please click this link (opens in a new window) : www.lightningreach.org/NBCapply This will take you through to our partner Lightning Reach. Important! Once you have connected in Lightning Reach, you must copy your Reference from Lightning Reach (in your confimation email) into the provided box below then submit your application form.

Lightning Reach Ref*

You have chosen to send the applicants bank statement please attach it here. *

Browse Files

(pdf, doc, docx, xls, xlsx, txt, rtf, zip, jpg, jpeg, png, gif)

Medical Evidence

Please attach any relevant medical evidence.

Browse Files

(pdf, doc, docx, xls, xlsx, txt, rtf, zip, jpg, jpeg, png, gif)

Consent

If you would like to view our privacy statement it can be found on the policies page of our website.

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 fulfilment of any award.*

YesNo

I consent to being contacted by the National Benevolent Charity to share feedback on my experience.*

YesNo

Statement by signing this form, I confirm that I have given a true picture of my circumstances.

Signature of applicant:*

Date

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

You must enter a valid email for the applicant, or choose someone else to be the application contact.

You must enter a valid email for the referrer.