Individual Application Form

Individual Application form

Date Received

Scheme

Charity You Are Applying To:*

Applicant's Information

Title (Mr, Ms etc)*

First Name*

Surname*

Address*

Town*

Post Code*

Telephone*

Your Email Address

Date of Birth*

How long have you lived in the Hackney Parish?*

Please tell us about any children or other people living with you, and how much they contribute to your weekly housekeeping

Name of Partner (if applicable)

Partner's Date of Birth

Partner age

Is your partner employed?

If yes, how much do they contribute financially on a weekly basis? £

Blank Space - Copy

Contributor 1 Name

Contributor 1 Relationship

Contributor 1 Age

Contributor 1 Employed?

Contributor 1 Amount £

Blank Space

Contributor 2 Name

Contributor 2 Relationship

Contributor 2 Age

Contributor 2 Employed?

Contributor 2 Amount £

Blank Space

Contributor 3 Name

Contributor 3 Relationship

Contributor 3 Age

Contributor 3 Employed?

Contributor 3 Amount £

Blank Space

Contributor 4 Name

Contributor 4 Relationship

Contributor 4 Age

Contributor 4 Employed?

Contributor 4 Amount £

Blank Space

Please provide details of how much money you have coming in each week.

Self: Attendance Allowance* £

Partner: Attendance Allowance £

Self: Bereavement Support Payment* £

Partner: Bereavement Support Payment £

Self: Carer’s Allowance* £

Partner: Carer’s Allowance £

Self: Child Benefit* £

Partner: Child Benefit £

Self: Child Maintenance* £

Partner: Child Maintenance £

Self: Children’s Tax Credit* £

Partner: Children’s Tax Credit £

Self: Employment Support Allowance* £

Partner: Employment Support Allowance £

Self: Job Seekers Allowance* £

Partner: Job Seekers Allowance £

Self: Pension Credit* £

Partner: Pension Credit £

Self: Personal Independence Payment* £

Partner: Personal Independence Payment £

Self: State Pension* £

Partner: State Pension £

Self: Take home pay* £

Partner: Take home pay £

Self: Universal Credit* £

Partner: Universal Credit £

Self: Working Tax Credit* £

Partner: Working Tax Credit £

Self : Any other income (Please state below) £

Partner: Any other income (Please state below) £

Self: Any other income statement

Partner: Any other income statement

Housing Costs

Is your house owned or rented*

Do you have a mortgage?*

If rented, How much rent do you pay each week?* £

Sheltered Housing?*

Hot water/heating charges each week* £

Do you receive Housing Benefit?*

If you receive Housing Benefit, how much per week?* £

Do you receive Council Tax Benefit?*

If you receive Council Tax Benefit, how much per week?* £

Savings and Debt

Do you have any savings?*

If you have savings, total amount* £

Do you have any debts?*

If you have any debts, total amount* £

How was the debt accrued?*

Is a repayment plan in place?*

Health and Social

Do you or a member of your family have any disability or ongoing health problems? Yes/No If yes please give details.*

Have you applied to the Hackney Discretionary Crisis Support Scheme for a grant? If so please give details.*

Have you applied to other charities of trusts for help? If so please give details*

Please describe in detail what you are asking for and why*

Amount requested* £

Statement

By ticking this box I certify that the information that I have given in this application is complete and correct to the best of my knowledge. I understand that this information may be shared with other charities or organisations if it is thought that additional support may be available from them. I give my consent for my personal and sensitive data to be shared with the Trustees and their data processors*

Please tick to confirm the statement above

Referring Agency

Referring agency name*

Referring agency contact first name*

Referring agency contact last name*

Referring agency contact position*

Referring agency telephone number*

Referring agency email*

Referring agency street address*

Referring agency town*

Referring agency postcode*

Have you checked your client is receiving his/her full entitlement to state benefits?*

Comments in support of the application*

Upload letter of support on headed paper*

No File Chosen

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Referees

Please give the name, address, phone number and email address of two individuals who will be willing to act as referees for your application. These could be either a religious leader, your GP or healthcare professional, local councillor, or someone of standing in your local community.

N.B. At least one referee must be from a different organisation to the Referring Agency.

Referee 1 Name*

Referee 2 Name*

Referee 1 Address*

Referee 2 Address*

Referee 1 Telephone Number*

Referee 2 Telephone Number*

Referee 1 Email

Referee 2 Email

Proof of Address

Please supply us with 2 recent utility bills and, if possible, a recent bank statement as proof of address.

Utility Bill 1*

No File Chosen

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Utility Bill 2*

No File Chosen

File uploads may not work on some mobile devices.

Bank Statement

No File Chosen

File uploads may not work on some mobile devices.

Equal Opportunities Monitoring Form

Please note that this information will help us ensure that we are accessible to all sections of our community.

Applicant's age

Gender Identity (Applicant)

Number of children

Single parent?

How would you describe your ethnicity?*

Do you or a member of your family have a disability?

Are you or a member of your family registered disabled?

Please note: Once submitted the application form cannot be accessed again so please ensure that all the information is correct.

Click On the Submit Button Once Only - It May Take Up To 30 Seconds to Complete - Thank You

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