Working Families Scheme

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 this fund)

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 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 - ANNUAL

Are YOU employed (full or part-time)?
YesNo

About YOUR income - all figures should be annualised

Please state any income you receive from the options below:

Gross Annual Income from Employment

Housing Benefit

Universal Credit

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

Child Tax Credit (NOT Child Benefit)

Personnel Independence Payment & Attendance Allowance

Any other Income

TOTAL ANNUAL INCOME

Do you have a spouse/partner?
YesNo

Does your Spouse/Partner receive ANY income from employment or benefits?
YesNo

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

Gross Annual Income from Employment

Housing Benefit

Universal Credit

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

Child Tax Credit (NOT Child Benefit)

Personnel Independence Payment & Attendance Allowance

Any other Income

TOTAL ANNUAL INCOME

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.