CONFIDENTIAL

/ Date received
Number and Fund

APPLICATION FORMFOR INDIVIDUALS

(Applicants under 18 and for higher/further education)

PLEASE RETURN THIS FORM by post to Cumbria Community Foundation, Dovenby Hall, Dovenby, CockermouthCA13 0PN.

If you are unsure about the meaning please contact a Grants Officer on 01900 825760

Please complete the form as fully and clearly as possible.

Mr/Mrs/Miss/Ms/other Full Name
Date of birth / Place of birth
Home address / Term time address (if applicable)
Telephone / Telephone
Email / Mobile
Years lived in Cumbria

Details of Secondary/Further Education

Dates / School/College/University attended / Qualifications gained

Details of applicant income (gross before tax) for the last two years

Dates / Occupation/Source of funding / Annual income
£
£

Please include support funding for example grants as well as earned income.

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Cumbria Community Foundation

Applicants under 18 and for higher/further education

Details of parent(s) or guardian(s)

Names
Home address (es)
Postcode
Email / Telephone
Ages of other dependent children in household (if any)

If parents are separated or divorced, please indicate which one you live with and the amount the other parent provides as financial support on an annual basis.

Details of household income (gross before tax)

Father/Guardian / Mother/Guardian
Source / Weekly income / Weekly income
Earned income / £ / £
Unearned e.g. rental income / £ / £
Benefits and allowances / £ / £
Maintenance / £ / £
£ / £
£ / £
Total / £ / £

If parent(s) is/are unemployed, retired or unable to work, please provide weekly amount of Income Support or benefits, pension, or special allowances etc.

Savings / £ / £

NBPlease provide evidence of household income: at least two recent payslips and confirmation of benefits receivable.

Other funding

Please provide information about other funding eg personal contribution and/or fundraising.

Please include details of applications made to the local authority or other body for grant aid or a student loan. If you have been awarded a grant/loan, please provide a copy of the notification of amount awarded.

Funder / £

Activity details

Proposed activity/course of study

College/University/Training provider
Course/Activity title
Details (length of study, full/part time,
location, start and end dates)
Course year eg 1st , 2nd, 3rd year

If you have received an offer or acceptance letter from the College/University/Provider, please enclose a copy of this document.

What do you want the grant to pay for?

Breakdown of proposed expenditure

Cost / £
Total amount requested

When do you expect the money to be spent by?

Please give details of any special circumstances or specific difficulties, which you feel should be taken into consideration when the Committee consider your application. This includes details of personal circumstances, for example special needs, and also how the grant will benefit the wider community.

Please give the name, position and contact details for a referee. This must be your education/training adviser.

Name
Position
Address
Telephone
Email

Checklist

Have you completed all sections of the form?

Have you enclosed copies of the following documents:

  • Offer or acceptance letter from College/University/training provider?
  • Notification of other funding?

Additional information

  • Curriculum vitae (useful but not essential)
  • Payslips and benefit information

Conditions and signature

If offered grant aid, you must agree to the following conditions:

  • you must claim the grant within three weeks of written offer. Unclaimed grants will then be withdrawn. Any other arrangement must be agreed in writing with your grants officer.
  • the grant will be used for the purpose for which it was approved.
  • you must provide details of how the grant was spent and how it has helped you. Reports and photographs may be used for publicity.
  • records will be kept of expenditure for at least five years and will be supplied to the Foundation if requested.
  • any proposed material change to the details of the application will be notified to us.
  • the grant is a donation and the Foundation is not liable for the consequences of its use.

Please sign and date below to confirm that the information provided is true and accurate

Applicant’s signature / Date
Guardian’s signature / Date

(Guardian’s signature required for applicants under age 18)

Should you be awarded a grant, please provide details of the cheque payee.

Payee

Applications may be submitted by email. A paper copy of the form with original signatures in ink must also be submitted. No award will be paid unless a signed form is provided.

Cumbria Community Foundation may request evidence to confirm information given on this form. The Foundation reserves the right to reclaim any money which has been paid as the result of fraudulent or misleading claims

Data protection: Cumbria Community Foundation will process information on this form. We will hold the information on computer. We may provide copies of the details to partner organisations including government bodies (eg Department for Work and Pensions or local council).

Please tick here if you do not want us to share information with other organisations.

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