Application for Grant Aid

Please use this application form to apply for grant aid from Bourne United Charities. This form can be used by the applicant or by a third party on behalf of the applicant. If help is required to complete, please visit the Citizens Advice Bureau at Wake House.

Application date

Applicant full name

Applicant email address

Applicant phone number

Applicant address (must be resident in the Parish of Bourne, Cawthorpe, Dyke or Twenty to qualify for assistance)

Is the address given, the applicants’ permanent place of residence?
YesNo

Please state your permanent place of residence?

Is it the applicants’ intention to continue living in the Parish of Bourne, Cawthorpe, Dyke or Twenty?
YesNo

Please state where you intend to live?

Applicant signature

If this form is completed by a third party, the applicant MUST STILL SIGN to give permission for BUC to contact and discuss the application with the third party

Signature:

Third Party Applicant Details

If this form is completed by a third party please give details

Third party name, job title, organisation, relationship to applicant (professional, relative etc.):

Contact details:

Signature:

Please be aware that BUC may need to verify financial information and make further enquiries to support your application. BUC has a duty to ensure the security of personal data. We will protect the information from unauthorised access, loss, manipulation, falsification, destruction or unauthorised disclosure.

We will keep your data only for the purpose for which it was collected and only for as long as it is necessary, after which it will be deleted. For the full GDPR policy please refer to our website www.bourneunitedcharities.co.uk or email admin@bourneunitedcharities.co.uk

Please tell us what it is you need and why?

Amount requested:

Details:

Please list any other organisations, local or national charities, statutory bodies (e.g. social services) that the applicant has applied to for financial help. Please give details of the amount applied for and any received.

Please list ALL benefits that the applicant is in receipt of such as Housing Benefit, Council Tax Benefit, Universal Credit, Income Support or PIP, for example.

Financial Information

INCOME - WEEKLY

Are YOU the Householder?
YesNo

Do YOU receive any income from employment, pensions or other benefits?
YesNo

Please state any income you receive from the options below:

Income from Employment

State Pension

Other Pensions

Housing Benefit

Universal Credit

Pension Tax Credit

Income from Land or Property (e.g. Rent)

Child Benefit/Child Tax Credit

Personnel Independence Payment & Attendance Allowance

Savings Income

Any other Income

TOTAL WEEKLY INCOME

Is your Spouse/Partner the Householder?
YesNo

Does your Spouse/Partner receive any income from employment, pensions or other benefits?
YesNo

Please state any income your Spouse/Partner receives from the options below:

Income from Employment

State Pension

Other Pensions

Housing Benefit

Universal Credit

Pension Tax Credit

Income from Land or Property (e.g. Rent)

Child Benefit/Child Tax Credit

Personnel Independence Payment & Attendance Allowance

Savings Income

Any other Income

TOTAL WEEKLY INCOME

OUTGOINGS - WEEKLY

Do you have any outgoings?
YesNo

Please state any outgoings you have from the options below:

Rent/Mortgage

Gas

Electric

Water

Council Tax

Loan Repayments

Purpose of Loan

Clubs/Membership fees (e.g. Swimming lessons etc)

Subscriptions (e.g. Netflix, Prime etc)

Phone Contracts/costs

Broadband

Food and consumables (e.g. cleaning products, sanitary products)

Clothing

Car Fuel

Services (e.g. Car, Boiler etc)

Car Insurance

Home Insurance

Pet Insurance

Other Insurance

Public Transport (e.g. Bus or Train fares to work)

Medical (e.g. Glasses, Hearing Aids, Dentistry)

Childrens School Trips

Other Essential Items

TOTAL WEEKLY OUTGOINGS

Does your Spouse/Partner have any outgoings?
YesNo

Please state any outgoings your Spouse/Partner has from the options below:

Rent/Mortgage

Gas

Electric

Water

Council Tax

Loan Repayments

Purpose of Loan

Clubs/Membership fees (e.g. Swimming lessons etc)

Subscriptions (e.g. Netflix, Prime etc)

Phone Contracts/costs

Broadband

Food and consumables (e.g. cleaning products, sanitary products)

Clothing

Car Fuel

Services (e.g. Car, Boiler etc)

Car Insurance

Home Insurance

Pet Insurance

Other Insurance

Public Transport (e.g. Bus or Train fares to work)

Medical (e.g. Glasses, Hearing Aids, Dentistry)

Childrens School Trips

Other Essential Items

TOTAL WEEKLY OUTGOINGS

SAVINGS

Do you have any savings?
YesNo

Please state how much you have in savings and investments.

Value held in Property/Land – other than your main residence.

Current Account Balance

Other Bank Accounts/Savings

Premium Bonds

Unit Trusts/ISAs or similar

Shares (approximate value)

Any other funds in UK or Abroad

TOTAL INVESTMENTS/SAVINGS FOR HOUSEHOLD

Does your Spouse/Partner have any savings?
YesNo

Please state how much your Spouse/Partner has in savings and investments.