Grant Request Form

Please Note: We cannot accept requests from individuals themselves.
This form must be completed by a third party responsible for referring the individual for a grant. After you submit the form, it will be emailed to the address given at the end of the form (Referrer details – contact email) so that you can reuse the information given to assist you with other grant applications.

Grant recipient details



Date of Birth


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.

Referrer details



Contact number

Contact email

WEC&R c-log reference number or other accounts reference if applicable

06. Fundraising – Have you applied to any other charities? If so please list those you will be or have applied to and how much pledged by any so far and how much you have left to raise.

Attach a file


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