APPLICATION FOR A BRUNTS CHARITY GRANT

Applicants for a Brunts Charity Grant should hold the following qualifications-

1.  Be in need, hardship or distress.

2.  Live within the Mansfield District Council Area or the surrounding area.

The Trustees in determining an application for a grant may also consider additional information dependant upon the number of applications made and the status of the applicants in relation to each other.

Grants can be payable under a number of circumstances either wholly or in part. Generally grants are paid to enable persons to afford an item or other matter to aid their everyday comfort or relieve any illness or disability.

Grants will not be paid on a recurring basis and will not be paid where a payment is the responsibility of a national or local government agency.

Data Protection

It is the Charity Commissions requirement that the Trustees must investigate the personal circumstances of applicants. The personal data supplied on this form and any other information including information relating to your circumstances if you become a beneficiary will be held on file. Some of these details may be checked with relevant organisations but none will be disclosed for any inappropriate purpose. You may have access to your personal information on request to the Trustees.

DETAILS OF APPLICANT/S

A.  Your Details.

Applicants Full Name. / Date of Birth
Address
Age
How long have you lived at this address?
How long have you lived within the Mansfield District Area?
If you do not live within the Mansfield District Area how long have you lived in the surrounding area.?
What is your Marital Status?

B.  Please provide details of anyone else who lives with you.

Name / Age / Relationship

C.  Your present accommodation.

Are you a lodger, owner-occupier, tenant, or have any other type of occupancy.(please state)

D.  Your Financial Information (please include that of any spouse or partner)

State Pension

/ £ / Per week/month
Private Pension / £ / Per week/month
Income support / £ / Per/week/month
Savings / £
Capital e.g. shares / £
Other income / £

E.  Why are you applying for a Grant ?

·  Please continue on a separate sheet if necessary.

F. Equal Opportunities. We are required by law to treat every applicant the same regardless of colour or ethnic origin. Please complete this section so that we can ensure we do not break the law. Your answer will not affect your application in any way.

How would you describe your ethnic origin? (please tick)

Applicant Partner

African
Asian
British/European
Caribbean
Irish
South East Asian
Combination of the above
Other-
Please state

G. Relationship to Trustees and Officers.

We are forbidden by law to “grant benefits” to our Trustees, Officers and their close relatives. To enable us to comply with the law can you please give details if you are a Trustee, Officer or one of their relatives?

Declaration. To the best of my/our knowledge I/We declare that the information we have provided is a true description of my/our circumstances.

Signed by Applicant

Signed by Spouse/Partner

Date

Please telephone 01623 623055 to make arrangements to return this form to the Brunts Charity Office together with your birth certificate, and details of your financial circumstances as you have stated on the form.

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