Grant Request Form

Grant recipient details

Name

Email

Date of Birth

Address

01. Living arrangements – does the applicant have any dependents or other adults living with them? Is the applicant a home owner or renting?

02. Health issues - do they have any disabilities or chronic health issues, mobility problems etc?

03. Financial situation – does the applicant receive any pensions, benefits or allowances (please give details). Does the applicant have any savings or any significant outgoings, debts etc?

For pensions, please state whether occupational, personal, or state pension, and the payee name, amount, and frequency of payment.

For benefits, please state whether it is Employment and Support Allowance, Income Support, Pension Credit, Universal Credit, Personal Independence Payment, Disability Living Allowance, Housing Benefit, Attendance Allowance, or Carers Allowance, and the payee name, amount, and frequency of payment.

Please also include any income from employment or elsewhere.

04. Family support - Does the applicant have family support and if so are family members able to contribute financially? (It is useful to rule this out before contacting the Society)

05. Grant requested details - what is the grant application for and how much is being requested? How will this improve quality of life? Please include quotes for any proposed work or item. We have a preferred supplier for carpets/flooring, but require a contact telephone number to arrange a visit to take measurements and quote.

Referrer details