Hornsey Parochial Charities
APPLICATION FOR A PERSONAL GRANT
Please complete this form as fully as possible in BLACK INK/FONT
Surname / First name / Title Mr / Mrs / Miss / Ms
Home address
Postcode
Number of years at this address
Telephone number / Email address
Are you / Single / Married / Widowed / Living alone / Living with partner
Age / Age of
partner / Number of children
living at home / Age of children
under 4 years / Age of children over 4 years
In fulltime education
Previous addresses / From (date) / To (date)
1.
2.
3.
4.
Are you employed/unemployed/self-employed/ retired?
Job title/nature of work if employed / Number of hours worked per week
Household Income / Income/benefits per week/month/year (delete as applicable)
Self / Other household occupants
Salary/wage / £
Job seekers allowance (JSA) / £ / £
Income support / £ / £
State Pension / £ / £
Pension credit / £ / £
Pension from employer / £ / £
Working tax credit / £ / £
Child tax credit / £ / £
Disability living allowance / £ / £
Personal independence payment / £ / £
Carers allowance / £ / £
Employment & support allowances (ESA) / £ / £
Budget loans / £ / £
Child benefit / £ / £
Bereavement allowance / £ / £
Universal tax credit / £ / £
Housing benefit / £ / £
Any other allowances or income / £ / £
If you have school age children do they receive free school meals / Yes / No
OFFICE USE
ONLY / New / Y N / Reg. / Y N / Last grant / / / / Amount / £
Estimates/quotes
Y N / Requested / / / / Received / / / / Supporting letter Y N / Requested / Received /
/ /
Are there any other family circumstances or information relevant to your application?
List any specific items and estimates of cost for which you are seeking financial assistance / Cost
1. / £
2. / £
3. / £
4. / £
5. / £
Total amount of grant applying for / £
Have you/ will you be applying to any other charities? / Yes / No
Details of other grants or financial assistance requested /received / Requested / Received
1. / £ / £
2. / £ / £
3. / £ / £
List any other relevant information to support your application
Please supply a supporting letter from a health care professional/supporting organisation/support worker
Supporting organisation
Name of support person / Job title/position
Address / Postcode
Telephone number / Email
I declare that to the best of my knowledge and belief the above details are true:
Signature / Name (print) / Date
Please post this application to:
Clerk to the Trustees, Hornsey Parochial Christies, P O Box 22985, London N10 3XB
Email: Tel 020 8352 1601 Website: hornseycharities.com
Enclose a copy of your estimates/quotes, all benefit letters and a supporting letter. Ensure that all relevant information is on this form. Your application cannot be process without the appropriate documents
Please state who the cheque is to be made payable to