Flooring 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:*

Has the applicant applied to the National Benevolent Charity before?*

YesNo

Approximate date of application: *

What was the outcome? *

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.

Are you renting privately?*

YesNo

Are you renting with a social landlord?*

YesNo

What is the name of your landlord?

How long have you lived at your current address?*

Less than 1 year1-2 years3-5 yearsOver 5 years

Please provide details of current circumstances, how much you are requesting from us and why?*

Please upload images of your current flooring*

Browse Files

Please upload a flooring quote*

Browse Files

Do you or someone living with you have a severe or enduring chronic physical health condition?*

YesNo

Do you or someone living with you have a severe or enduring chronic mental health condition?*

YesNo

Please upload medical evidence of diagnosis*

Browse Files

Has the applicant applied to other charities?*

YesNo

Other application details?

What was the outcome?

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.

Please review the "How to apply" section on the individual grants page of our website if you are not sure who can refer you.

Organisation:*

Job title:*

Referrer Name:*

ForenameSurname

Postal Address:*

Address

Address Line 2

City

Postcode

Referrer Email:*

Confirmation Email

Referrer Phone:*

For Referrers

Please give a description of the applicant’scurrent circumstances, what they are applying for, how you are involved withthem and that you support the application.*

0/300

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

When did you last have contact with the applicant?*

Bank Statements

To assess the application, we will need to see bank statements belonging to the applicant and any other adults in the household which are 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 statements 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 bank statements (not more than 2 months old) belonging to the applicant and any other adults in the household

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, please return to this site to submit your application form. You must copy your Reference from Lightning Reach into the provided box below

Lightning Reach Ref*

You have chosen to send the applicants bank statements please attach them here. *

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 fulfillment 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.