General Application Form

Gargrave Lands Charity

Registered Chairty No: 225067

General Application Form
Purpose: The charity provides financial assistance to any permanent resident of Gargrave, Eshton, Flasby, Coniston Cold, Bank Newton or Winterburn provided that, in the trustees' opinion, any such assistance is justified by the circumstances of the case. This assistance may be by way of grant or loan.

Ensure that all information is accurate. Ask a Trustee for help if you are unsure. A copy of the Charity's Privacy Notice is available on the website.

Full Name

TitleFirst NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry
Have you lived there for more than 6 months?
If less than 3 years, state previous address
Are you on the Electoral Role?
Home Phone Number

Area CodePhone Number
Mobile Number

Phone Number
E-mail
Are you:
Number of people in the household (including anyone with you temporarily)

Please details other people resident at your address, their relationship to you and whether they are dependant on you for financial support. If nobody else at address, please write N/A.

Rows	Name	Relationship	Dependant/non-dependant
1
2
3
4

Number of wage earners at household (include in income declaration)

State amount of ALL the following.

Rows	You (£)	Spouse/Partner (£)	Others (£)
Savings
Investments
National Savings
Bonds
Stocks/Shares
PSB's

Number of cars at household

Do you own, rent, finance or have a bank loan on your car?

Rows	Car Details
No Car
Registration
Make
Model

Please give details of your property (please tick).

Rows	Owned outright	Owned with mortgage	Private rental	Local Authority/Housing Association Rental	Other (please state)
Service Quality

If property is owned, please state current market value.
£

State the current market value of any financial interest anyone in the household may have in any other property/asset or business that has not already been disclosed above.

Rows	You	Spouse/Partner	Others
Details

Do you or anyone in your household have any of the following registered against them?

Other
If yes, please give full details including dates, amounts, reasons etc.
Are there any outstanding debts? (Please include all loans, HP, credit & store cards). State company name, total amount borrowed, current amount outstanding, monthly payments and total of any arrears. If none, write N/A.

Please list your total monthly income. * It is important to include all benefits from the State in relation to unemployment, child benefit, disability, maternity/paternity and any other state benefit.

Rows	Monthly Income (£)
Income from employment
State pension
Income from any other pension
Income from ALL state benefits - see note above*
Maintenance payments (for dependent children)
Income from investments such as shares or bonds
Bank and Building Society interest payments
Any other income
Total income

Please list your total monthly expenditure.

Rows	Monthly Expenditure (£)
Mortgage or rent
Council tax
Electricity
Gas
Water
Heating Costs
Average weekly food bill
Travel costs including car or public transport
Childcare
Loan payments
Credit or store card payment
Internet costs
Mobile phone costs
TV Subscriptions (eg Sky, Netflix, Prime)
Any other expenditure
Total Expenditure

Please give us your full bank, building society or Post Office account details so we can credit any grant payment direct to your account.

Rows	A/C Name (s)	Name of Bank	A/c Number	Sort Code
Service Quality

Please state clearly what assistance you are seeking from the Charity. Please give full details of the amount and purpose.

0/500
Please tell us about any special circumstances or any other information which you think may assist the Trustees to reach a decision on your application.

0/500

Signature (Please type your name)
Date Completed

MonthDayYear
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