Thatcham Parochial Almshouse Charity

Private and Confidential

Thatcham Parochial Almshouse Charity

Charity No 239850

Council Offices, Brownsfield Road, Thatcham, Berkshire, RG18 3HF

Please reply to: Clerk to the Trustees, Mrs J A Davis

APPLICATION FOR ALMSHOUSE

Applicant(s):

1) Surname………………………….. Forenames…………………………………

2) Surname………………………….. Forenames…………………………………

Single/Married/Divorced/Widowed/Partnership………………………………….

Resident in the Ancient Parish of Thatcham for……………..years.

1) Age……….Date of Birth………………….Place of Birth………………………

2) Age……….Date of Birth………………….Place of Birth………………………

Occupation(s), if any………………………………………………………………………

Address……………………………………………………………………………………………………………………………………………………………………………..…………………….

………………………………………………………………………………………………………

…………Post Code……………Tel:………………………………

Details of present accommodation:

House/Flat/Bungalow/Lodgings………………………………………………………

Number of rooms you occupy…………………

Do you own the accommodation? Yes/No

If “yes”, what is the estimated current value?......

Do you own the furniture? Yes/No

Are there any other persons living with you? Yes/No

If “yes”, how many?......

Contacts:

Next of Kin:

Name…………………………………… Name……………………………………..

Address………………………………… Address…………………………………..

…………………………………………… …………………………………………….

Tel:………………………………………. Tel:………………………………………...

The Almshouses are not warden controlled. Are the above prepared to take responsibility for your welfare if you become ill?......

……………………………………………………………………………………………….

Private and Confidential

HEALTH

First Applicant: Name………………………………………………………………

Address…………………………………………………………

Please ask your doctor to state his/her support of your application and that, in his/her opinion, you are capable of looking after yourself.

It is essential that residents are able to cook, clean and look after themselves. When this is no longer possible, it is necessary to find other accommodation.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Signature…………………………………Doctor’s Name……………………………….

Address of Practice/ Surgery/Medical Centre

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Second Applicant: Name…………………………………………………………….

Please ask your doctor to state his/her support of your application and that, in his/her opinion, you are capable of looking after yourself.

It is essential that residents are able to cook, clean and look after themselves. When this is no longer possible, it is necessary to find other accommodation.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Signature…………………………………Doctor’s Name……………………………….

Address of Practice/ Surgery/Medical Centre

Private and Confidential

FINANCIAL STATEMENT

Total Savings:

Annual income from savings and investments:

Total outstanding debts:

Monthly Income: / £ / Monthly Expenditure / £
Salary / Rent/Mortgage
Retirement Pension / Ground rent
Private Pension / Council Tax
Pension Credit: / Electricity
Widows Payments / Gas
Income Support / Water
Care Allowance / TV Licence
Disability Allowance / Telephone
Attendance Allowance / Food
Other (details) / Travel
Other (details)
TOTAL / TOTAL

Other financial considerations not covered above:

Private and Confidential

Please give your reasons for making this application:

I AGREE that, if I am appointed to an Almshouse flat, I shall occupy it as a beneficiary of the Almshouse Charity and not as a tenant. Any weekly sum I pay should be regarded as a maintenance contribution, not as rent.

I DECLARE that, to the best of my knowledge, all the foregoing statements are true.

1) Signed…………………………………………………Date………………

2) Signed………………………………………………….Date………………

N.B. Applicants should note that the selection of the successful applicant will be made by the Trustees of the Almshouse Charity and that their decision is final.