REGULAR GRANT APPLICATION FORM
Parts 1-3 should be completed by Applicant
Parts 4-5 should be completed by Minister
Tick one box when asked Yes : No
Answer all questions in BLOCK LETTERS
PART 1 – About you the Applicant
A. Surname: Mr./Mrs./Miss/Ms.
B. Christian Name(s)
C. Full Address
D. Congregation Cheque Payee Name
E. Children (aged 23 years and under)
Surname and Christian Name(s) : Date of Birth :Name of School/College
PART 2 - Income Average Net
WeeklyIncome
£ (or €)
Applicants Earnings
Financial Contributions by other adults to family income
Child Benefit
Bereavement Allowance[ ] : Widowed Parents Allowance[ ]
Occupational/State Pensions
Guardian’s Allowance
Investment Income [This includes all income from dividends, stocks, bonds, bank & building society interest. It does not include the capital sum]
Income Support[ ]: Tax Credits [ ] : Rates Rebate [ ]
Housing Benefit [ ] : Job Seekers Allowance[ ]
Employment & Support Allowance (ESA)
Disability Living Allowance [ ] : Incapacity Benefit [ ] : Industrial Injuries Benefit[ ]
Attendance Allowance [ ] : Carers Allowance[ ]
All other sources, e.g. maintenance/land letting (please specify)
TotalAverage Net Weekly Income______
PART 3 - ExpenditureAverage Net
WeeklyExpenditure
£ (or €)
Rent or Mortgage repayments
Rates
Ground Rent
Structural Insurance for home owners
(does not include house/life insurance or living costs)
Water Rates (Eire only)
School Fees/Childminder Fees
Total Average Net Weekly Expenditure______
Declaration by Applicant
Should this application be accepted, I promise and agree to accept and abide by the decisions of the Governors and to adhere to the regulations of the Society:
Applicant’s SignatureDate
For Office Use Only
PART 4 - To be completed by the Minister
A.What are the current circumstances of the child(ren)?
The father and mother are deceased
The father is deceased
The mother is deceased
The father is separated/divorced
The mother is separated/divorced
The father is disabled/ill
The mother is disabled/ill
The mother is single (unmarried)
Other (please specify)
B.Are the family under the pastoral care of the Congregation?YESNO
C.Is/was the father a Presbyterian?YESNO
D.Is/was the mother a Presbyterian?YESNO
E.Please give any information which you consider may be helpful to the Governors in their assessment of the application:
PART 5 - Certificate
I hereby certify that the child(ren) belong to the Presbyterian Church, and that to the best of my belief all the information contained in the application is true and complete.
NAME OF MINISTER (PRINT NAME) ______
Signature of Minister ______Date ______
Congregation ______
INFORMATION
QUALIFICATION OF CHILDREN:
1.A child, whose parents are both dead, one of whose parents is dead, one of whose parents is disabled, whose parents are separated or divorced, whose mother is single, or whose parents are unable to provide.
2.A child belonging to the Presbyterian Church in Ireland and a child of parents, one or both of whom belong or have belonged to the Presbyterian Church in Ireland.
3.A child of not more than 23 years of age (other than in exceptional circumstances).
For a full statement of qualifications and circumstances in which a child may cease to qualify, please refer to the Scheme No. 58 of the Society, paragraph 16 as amended
A child is encouraged to attend Bible Class, Sunday School or any other Christian Youth group connected to a Presbyterian Church
NOTE
Selection of children to the roll takes places twice a year in April and October.
This completed form should be returned as soon as possible. If you do not receive an acknowledgement of its receipt within ten days, or if you have any further enquiries, please contact:
Dr Paul Gray
The Presbyterian Children’s Society
Glengall Exchange
3 Glengall Street
Belfast BT12 5AB
Telephone-028 90323737