Application Form Guidance Notes

One-off Grant Application Guidance Notes
Who is eligible for financial assistance?
Men and women who live in England or Wales aged 60 or over (over 50 for homeless people), with
a low income and minimal savings, are eligible for support. People who are not eligible for help
from any other trade, professional or Service benevolent fund will be given priority. We do not
award grants to people living in residential care.
How to apply
The application form should be completed by a third party organisation such as Age UK, Care &
Repair, Social Services, Citizens Advice or other welfare support agency. If the applicant is unable
to find a referring agency to assist them, please contact the Supporting Friends team to discuss
this. We aim to respond within four weeks of receiving the completed form.
Please return the completed form to Supporting Friends, Friends of the Elderly, 40-42 Ebury Street,
London, SW1W 0LZ, or by email to: [email protected]
How can Supporting Friends help?
We aim to improve the quality of life for older people in the following ways:
 by providing one-off grants for essential items such as mobility aids, basic furniture,
household white goods and appliances, property repairs and utility bills;
 with regular allowances to support older people living at home who are on a very low
income;
 by signposting to other potential sources of funding
The scope of the grants is wide, but regrettably no help can be given with Council Tax payments,
care home fees, rent arrears, overseas travel or for items for younger members of a household. We
cannot make payments in retrospect for items already purchased.
When the application is successful
A cheque for a one-off grant will be made payable to the referring organisation (or company
providing the service or item), but not to an individual applying for assistance.
For more information contact Supporting Friends
If you have any questions regarding this form please contact the Supporting Friends Team on 020
7730 8263. You can also email: [email protected]
About Friends of the Elderly
Friends of the Elderly has been helping older people since 1905. Our vision is that all older
people should retain their independence, dignity and peace of mind. We offer high quality
residential and nursing care in care homes in the South East and in Worcestershire. We support
older people to stay living in their own homes with a range of community services including day
clubs, home support and befriending.
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Guidance notes for completing the application form
To be read fully before completing the application. Please supply all supporting papers
requested and information as detailed below to ensure a quick response.
1.
Applicant’s Personal Details
Please supply all the information that is being asked for in this section.
Religion – this can be helpful in identifying sources of funding, since there are some organisations
which fund clients of particular religious affiliation.
2.
Alternative Contact Details
Please give details of an alternative contact or next of kin
3.
Health
Health problems or disabilities – this can be helpful in identifying sources of funding, as some
organisations support people who have particular health problems. This may also help when
interacting with the applicant where necessary.
4.
Employment History
Please supply this information even if the applicant and their partner are retired or if the
companies are no longer in existence.
There are many trade and professional benevolent funds that support people who have worked in
particular fields. For some occupational benevolent funds even a short period of employment
may entitle the applicant to financial assistance.
Please indicate if the applicant was a member of a trade, professional body or trade union during
their employment. This information is useful since many trade and professional bodies and trade
unions support their members even if membership has now lapsed.
If the applicant had many different employments, please give details on a separate page.
Partner’s Employment History
Please supply this information even if your partner is now retired or deceased as some
organisations support clients upon their partner’s employment even if their partner is now
deceased.
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5.
HM Forces History
There are many funds that help people and their partners who have served in any of the Armed
Forces, such as the Air Force, Navy or Army. If your client has served in the Forces they can apply
to the Royal British Legion or SSAFA Forces Help for financial assistance.
6.
Household Information
This information is required, in order that we may have an overall view of the household. Please
state how many people live in the household and if they are under 60, state their relationship to
the client (e.g. son, daughter, carer etc.).
7.
Details of Housing
Please complete the boxes to indicate whether Housing and/or Council Tax Benefit have been
claimed.
If the applicant is in rented accommodation, please indicate whether the property is rented from
the Council, a Housing Association or a private landlord.
If the applicant is a home owner with a mortgage please give the amount of the monthly mortgage
payment. State the amount paid by the applicant, over and above any direct payments from
Pension Credit/ESA.
8.
Details of Income and Expenditure
Income information is needed for both the applicant and the applicant’s partner (if any) and
should be stated in terms of a weekly figure if possible. If there are other members of the
household, please give their income in the column headed ‘Other’.


Please attach a copy of proof of income and expenses to the application form as follows:
The most recent benefit letter from the DWP, Pension Service or Jobcentre Plus
Most recent bank, building society or Post Office Card Account statement showing at least 2
months of transactions
Disability Related Expenditure: This might include extra costs for home care, transport, cleaning,
gardening, chiropody, dietary requirements, heating. Please state the type of activity paid for and
the average amount spent per week.
9.
Details of Bank Accounts and Savings
Please give the amounts of any bank and building society balances and details of all other savings.
Please check with the client whether they (or their partner) have another property, other than
their main home.
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10.
Debts and Arrears
Please give details of outstanding debts and arrears. Do not include any current bills which are
due to be paid, but which are not in arrears.
11.
Details of Grant
Please describe what the client has applied for help with e.g. an electric cooker. Include an
explanation of why the item/service is required. If more than one item is requested, please
indicate which is the most important. It will speed the application process if quotes for the items
being requested are provided with the application. If the client needs help with their utility bills,
please enclose a copy of the recent bill.
If the applicant has applied to us for support on a previous occasion please give the approximate
date of the application.
If a grant is agreed the cheque will not be made payable to the applicant. Cheques will be made
out to referring agencies, or a product/service provider.
12.
Other Funds Approached
Please give the names of any other charities applied to and the result of those applications (if
known).
12.
Referring Agent
Please note that this section needs to be filled in by the referring agency whose contact details will
then be used for all further correspondence in connection with the application.
14.
Declaration
The applicant should read the declaration and, when satisfied that all the information given is
accurate, sign and date the form.
The form should also be signed by the applicant’s partner (if any) to confirm that the information
about them is accurate.
PHONING FRIENDS
Phoning Friends is a service operated by Friends of the Elderly, offering regular friendly phone calls
from a trained volunteer. If the applicant would benefit from this service please state this on the
application or contact our Phoning Friends Manager for information on 020 7730 8263. Older
people who have feelings of loneliness and isolation are a priority for this service.
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ONE OFF GRANT APPLICATION FORM - WS
(Please read Guidance Notes before completing this form)
1. Applicant’s Personal Details (see note 1)
Last Name
First Name
Title
Date of Birth
Place of Birth
Religion
Marital Status
NI Number
Home Address
County
Post Code
Telephone Number
Partner’s Personal Details (if applicable)
Last Name
First Name
Title
Date of Birth
NI Number
Living at above address? Yes/No
2. Alternative Contact Details (see note 2)
Name
Relationship to Applicant
Address
Postcode
Telephone Number
3. Health (see note 3)
Please describe any health problems or disabilities that the applicant or their partner may have:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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4. Past Occupations (see note 4)
Please tell us about any past paid employment in the UK:
Applicant’s Employment History
1
2
3
Employer Name
Job Role
Type of Business
Length of Employment
Employer Name
Job Role
Type of Business
Length of Employment
Employer Name
Job Role
Type of Business
Length of Employment
Partner’s Employment History
1
2
3
Employer Name
Job Role
Type of Business
Length of Employment
Employer Name
Job Role
Type of Business
Length of Employment
Employer Name
Job Role
Type of Business
Length of Employment
5. HM Forces History (see note 5)
Did the applicant serve in HM Forces
Did the applicant’s partner serve in HM Forces
Yes/No
Yes/No
If yes, please state which service and for how many years
_______________________________________________________________________________________
6. Household Information (see note 6)
How many people live in the household?
Please give details of any household members under the age of 60:
7. Details of Housing (see note 7)
Has Housing Benefit been
Has Council Tax Benefit
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claimed?
been claimed?
7. Details of Housing (continued)
Please indicate the applicant’s type of accommodation by ticking or completing the relevant boxes
below:
Housing Association
Rented
(if yes,
please circle type)
Owned – No Mortgage
Council
Owned – With Mortgage:
Please state monthly mortgage
payment, excluding payments £
made direct from Pension Credit or
ESA.
Private
Hostel
Has the applicant
been recently
homeless?
Yes/No
Care Home/Residential Home
If yes, when were
they re-housed?
8. Statement of Income (see note 8): ATTACH COPY OF PENSION CREDIT LETTER OR OTHER PROOF OF INCOME
Details of Weekly Income
Applicant
£
Partner
£
Other
£
Basic State Pension
Pension Credit (Guaranteed Credit)
Pension Credit (Savings Credit)
Private/Occupational Pensions - total
Employment Support Allowance
Net Weekly Earnings
Carers Allowance
Any other income – please specify
Weekly Total
£
£
£
£
£
£
Attendance Allowance
Disability Living Allowance – Mobility
Disability Living Allowance – Care
Charitable Income – please specify
Weekly Total
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Disability Related Expenditure (see note 8)
If the applicant has any expenses as a direct result of disability, please describe these below and
estimate the average weekly expenditure figure in the box
£
9. Bank Accounts and Savings (see note 9)
Applicant
£
Partner
£
Other
£
Bank account – current balance
Building Society – current balance
Post Office accounts – current balance
Other savings (including ISAs and premium
bonds)
TOTAL
£
£
£
Does the applicant own any property (other
than their own home)?
10. Debts and Arrears (see note 10)
Indicate the total amount still owed and (where appropriate) the weekly repayments being made.
£ Total Owed
£ Weekly Repayment
Rent, Mortgage, Council Tax
Gas, Electricity, Telephone or Water Charges
Credit cards, Bank overdraft, Catalogue or loans
Social Fund
Other (please explain)
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11. Details of Grant (see note 11)
What is to be purchased with the grant? Please give full details of the applicant’s circumstances and the
reason the grant is required:
If a grant is approved, who should the cheque be made payable to? Please attach a quote for the item or
service.
Please note, the cheque will not be made payable to the applicant. Cheques will be made out to referring
agencies, or a product/service provider.
What is the total amount needed?
£
Has this client been referred to Friends of the Elderly before?
If yes, please give the date:
Has this client applied to the Local Authority for help to provide the item requested?
Yes / No
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12. Other Funds Approached (see note 12)
Have any other charities been applied to on behalf of this applicant?
If yes, please list and state the outcome, if known:
1
4
2
5
3
6
Yes/No
13. Referral Agency’s Details (see note 13)
Supporting Friends will correspond with the referring agency in connection with this application.
Your Name (please print)
Your organisation
Address
Telephone number
Email
Signature of Referring Agent
14. Declaration to be signed by the applicant (see note 14)
I hereby certify that the information given is correct to the best of my knowledge and belief. I agree that Supporting Friends may
approach any other charities or organisations in order to consult in confidence on matters relevant to this application. I authorise
Supporting Friends to approach other agencies on my behalf.
In order for Friends of the Elderly to be able to process this application, it has been necessary to ask for personal information, such
as health, finance, religion and background. The Data Protection Act 1998 is in place to make sure that organisations do not
misuse such information. To comply with the Act, Friends of the Elderly needs to have explicit consent to hold such information,
either in manual or computer files. I agree that Friends of the Elderly/Supporting Friends may hold and process personal data
about me in its manual and computer files.
Signed (Applicant)
Signed (Applicant’s Partner, if applicable)
Date:
Date:
Phoning Friends
Phoning Friends is our telephone befriending service, and creates friendships on the phone
between volunteers and clients. We will match you to a volunteer befriender, based on
shared interests and compatibility. Your volunteer will phone you regularly for a friendly chat,
either once a week or fortnight. If you are interested in this free service please tick the box.
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Monitoring Form
Please complete this form which helps us to monitor applications for equality purposes.
This is sensitive personal data and will be treated as confidential, in line with the
requirements of the Data Protection legislation. The data will only be used for general
statistical and monitoring purposes. The data will not be taken into account in assessing
information on your application form.
Ethnic origin
Ethnic origin is not about nationality, place of birth or citizenship. It is about broad ethnic
groups.
ETHNIC ORIGIN
To which one of the following groups would you say you belong? (Please tick one
option only).
White
 British
 Irish
Any other White background (please specify) ……………………………………
Mixed
 White and Black Caribbean
 White and Black African
 White and Asian
Any other mixed background (please specify) ……………………………………
Asian or Asian British
 Indian
 Pakistani
 Bangladeshi
Other Asian background (please specify)……………………………………… …
Black or Black British
 Caribbean
 African
Other Black background (please specify) …………………………………………
Chinese or other ethnic background
 Chinese
Any other ethnic background (please specify) ………………………………………
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