The Deakin and Withers Fund Application Form

The Deakin and Withers Fund Application Form

Established in 1852, the Deakin & Withers Fund was founded thanks to the legacy of Thomas Deakin, a Sheffield businessman. Now, the fund is administered by SYCF and we are dedicated to ensuring that legacy can continue to help people.

Who Can Apply?

Single, divorced, or widowed women over 40, who are in need, hardship or distress.

And

People applying must be members of a church which is a member of ‘Churches together in England’ or ‘Churches together in Britain and Ireland’.

We do not fund:

Anything already paid for
Holidays

When filling in this application form:

This application form requires some of your personal information. We require these details to ensure we reach a fair decision. Your application will be kept confidential and we will never pass your personal information to any other parties.

Please note: This form must be read and witnessed by the Minister of your Church before submission.
How we will deal with your application:

Once we have received your application we will contact you by telephone, e-mail or letter with any enquiries and to inform you when we have reached a decision.
We may also contact the Minister of your Church as a part of the assessment process.
Please also be aware that we sometimes require evidence of anything stated on your form. Please ensure that you have the information available, if requested.
If your application requests support with bills, then a copy of your bill(s) is required. If you require a household item then quotes for the item are required and must be sent with this application.

Please note: If you are unsure if you need to send anything with your application then please get in touch. We are happy to help.
How long does it take?

It usually takes a few weeks to process requests. Our decision making panel will aim to review your application within six weeks of submission. If you are successful then we will notify you of your success and the payment will be made directly to your bank/building society account.

If we are unable to help you with a grant award then we will notify you of our decision.

Please note:The Trust cannot disclose reasons why a grant is not awarded. Trustee decisions on your application are final.
Applying to the Trust again:

If youare successful andreceive an award from the Trust, you can reapply again after 12 months.
Helpful resources:

This fund is not a crisis fund and it is not intended to provide a regular income.

We advise:

You go to your local Citizens Advice Bureau or equivalent organisation to receive free, impartial advice and practical help with any financial issues.
You ensure that you are receiving any/all state benefits to which you are entitled.
For help with benefit claims you can seek advice and support from a Citizens Advice Bureau or your local council.
You may also find it useful to check the Turn2Us website - the Christian’s Against Poverty website –

Enquiries:

If you have any questions about completing your application then please get in touch.

Tel: 0114 242 4294

Email:

The Deakin and Withers Fund –Application Form

Please complete all sections of this form as fully as possible, in BLOCK CAPITALS. If you have any queries regarding any of the questions please contact us to discuss.

SECTION ONE – PERSONAL DETAILS

Mrs / Ms / Miss / other title (please specify)
First name(s)
Last name
Address
Postcode
Telephone number (including dialling code)
Email address (if applicable)
Date of birth / __/__/____
Please indicate which of the following apply / Single or Divorced or Widowed
(please circle)
Do you live: / alone
(please tick) / with partner
With dependent(s) / Age(s)
with relatives
with friends
Additional Household Members: (if any) Weekly contribution to household expenses
Name & Relationship
1
2
3
Health and mobility – please provide details of any health difficulties, problems with mobility, illnesses relating to yourself or any dependants.

SECTION TWO – YOUR NEED

How much money are you asking for?

£______

What will it be used for?(I.e. to pay off debts, boiler repairs etc.)

Why do you need this grant?If necessary continue on a separate sheet.

SECTION THREE – YOUR INCOME

Do you receive benefits? If so, please state below how much and how often you receive them.
Income support / £ / per
Housing benefit (Please include rent details even if paid directly to landlord) / £ / per
Personal Independence Payments / £ / per
Disability Living Allowance / £ / per
Pension credit / £ / per
Child Benefit / £ / per
Child Tax Credits / £ / per
Employment Support Allowance / £ / per
Jobseeker's allowance / £ / per
Universal credit / £ / per
Other (Please give details) / £ / per
Do you receive a pension? If so, please state below how much and how often you receive your pension.
State pension / £ / per
Private pension(s) / £ / per
Any other Income / £ / per
Please provide details of any investments you have e.g. rental properties, bank accounts, shares, building society accounts, premium bonds etc. Please include cash in the home.
Type of investment / Amount
£
£
£
£

SECTION FOUR – YOUR OUTGOINGS

If you rent a property
Please state your current rent per week / £
Is this to a private or council landlord?
Do you receive discretionary Housing Benefit payments? (Please circle) If YES, how much do you receive? ______per____ / Yes / No
If you own the property where you live
Please state current value / £
Please state current mortgage outstanding on the property / £
Please state current mortgage payments per month / £
How much council tax do you pay per month? / £
Do you receive council tax benefit? (Please circle)
If YES, how much do you receive?
______per ______/ Yes / No

Additional Information

Please provide a copy of your most recent bank/building society statement showing any benefit payment(s). Please note: This should be signed by you to say it is a true copy of the original.
Please attach comparatives quotes for the item(s) OR the service OR a copy of your bill(s) which are relevant to your application.
Have you applied to the fund before?
If yes, please give the date you applied. /
___/___/_____
Have you applied to your Local Authority/DWP/Social services for help to provide the item requested? / Yes/No
Have you applied for a benefit for which you are still awaiting the outcome? / Yes/No
Have you applied to any other charities/trusts? / Yes/No
Are you receiving any advice from an agency such as Citizens Advice Bureau? If YES please give details: / Yes / No

If you have answered yes to either of the last two questions, state the amount requested and the outcome, if known

Where have you applied / Type of benefit requested / Amount requested / Outcome
£
£

Declaration to be signed by the applicant

I hereby certify that the information given is correct to the best of my knowledge and belief. I agree that the Deakin and WithersFund may approach any other charities or organisations in order to consult in confidence on matters relevant to this application. In order for the Deakin & WithersFund to be able to process this application, it has been necessary to ask for personal information, such as health, finance, religion and background. The Data Protection Act 1998 is in place to make sure that organisations do not misuse such information. To comply with the Act, South Yorkshire Community Foundation's (SYCF) needs to have explicit consent to hold such information, either in manual or computer files. I therefore consent to SYCF holding on file the personal information that I have revealed in this application form.SYCF’s registration number under the Data Protection Act 1998 is Z657900X.

Signed (Applicant) / Date
Please give details of the Church/Centre that you attend.
Name of church/centre
……………………………………………….. / Name of the Minister of Religion
………………………………………...
Address
………………………………………………...
………………………………………………..
Postcode………………… / Telephone Number…………………………
E-mail address…………………………..
Your signature must be witnessed by the Minister of Religion, in signing this form the Minister confirms you are in need, hardship or distress and a Church member and that the information contained in the application form is to the best of their knowledgecorrect. By signing you confirm that the Church is a member of Churches Together or is a Churchhaving full membership of Churches together in Britain and Ireland.
Signature of Minister / Date
Please add your own comments about the applicants circumstances here

Thank you for completing this form. Please return to:Grants Team, SYCF,Riverside Works, 9-12 Jessops Riverside, 800 Brightside Lane, Sheffield, S9 2RX.

How did you hear about this fund?

South Yorkshire’s Community Foundation Ltd No. 7545536 Charity No. 1140947