Hyman Mark Application

Hyman Marks Application
Please Select

I am filling in the application on behalf of anotherI am wanting to apply for a grant

The Agency
Your organisation
Your Contact full name

First NameLast Name
Your Organisational contact email
example@example.com
I agree that I have;

consent to give you the details of the person/s receiving the grantI do not have consent to give you the details from the person/s receiving the grant
Name of the grant recipient

First NameLast Name
Email of recipient
example@example.com
Phone of recipient

SufixPhone Number
Address of recipient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth of recipient
Number of people living in the recipients home
Number of dependents living in the recipients home
What benefits are the recipients receiving

BenefitDisabilityAllowance for dependent children
If the applicant is repaying money to Work and Income, please state or provide Work and Income Benefit summary letter or Benefit and Debt summary printouts from their MyMSD:

Cancelof
Iwant to budget sheet signed by a budget advisor

I have budget sheet signed by a budget advisorI want to fill in a budget here

Budget
Total weekly salary/wages and other earnings from all household members:
Total weekly work & income support from all household members:
Total Income
Budget
Rent/mortgage
Food
Insurance
phone mobile
power
car exps fuel
Debts or loyalty payments
other expenses
Total Weekly expenses
Balance
Please upload supporting documentation like bank accounts and invoices

Cancelof

Other Details
Please tell us about your application for help with a domestic/financial crisis.
Applications are strictly confidential, so please write about your situation as fully as you feel able and note any important factors such as family crisis, health, housing, special needs, work and debts. If you can please outline how this grant may help to improve your longer term situation and future.
List what is being applied for include quotes invoices and power bills. Firewood simply state firewood as we have our own supplier.

Agreement
I;
confirm that I have explored, accessed and exhausted all other funding options, including Work & Income entitlements or advances, have provided quotes, bills and payee/supplier payment information and I declare that the information provided is true and correct to the best of my knowledge.
In signing this I declare that all the information is to the best of my knowledge true and correct. I also declare that I have met and interviewed this person and have gathered sufficient information to support this application. Social services signature.

Our confidentiality declaration

Your completed application will only be viewed by the Trustees and Manager.

The Trustees and Manager will keep confidential all information regarding applicants and their applications that is transferred verbally, in written and electronic form.

Where further information about the application is required, this will only be with the consent of the applicant, and for the purposes of considering the application.

Consent. By submitting this application, you consent to us consulting with support people, dental and health professionals or any other parties regarding your application. This is to better understand your situation and how this meets the application criteria.
Signature

Clear
Should be Empty:

Hyman Marks Application