THE HAMPSTEAD WELLS AND CAMPDEN TRUST

APPLICATION FOR INDIVIDUAL/FAMILY SUPPORT GRANT

The Hampstead Wells and Campden Trust (“the Trust”) will use the personal information about the applicant and other individuals which areprovided on this form and elsewhere to administer the application and monitoring process and any grant which is awarded. Such personal information may be shared with the organisation which has referred the applicant to the Trust to provide confirmation of the outcome. [The Trust may also seek consent from the applicant to share the personal information with other organisations and persons whom the Trust considers may be able to assist the applicant.]

The information collected may include sensitive personal information such as details of the applicant’s disabilities or health conditions, and by submitting this form the applicant confirms that they are happy for the Trust to use such information as described above.

All individuals named in this form must be provided with the information above and must agree to the submission of this application. Wherever possible, the applicant should sign at the end of this form to confirm their agreement, and that of any other individuals named in this form, to this application. If you are submitting this form without the applicant’s signature, you confirm that the applicant and any other individualsnamed in this form have been provided with the information above and have consented to the submission of this application.

  1. Details of Applicant(s) and Household Composition:

NAME / AGE / OCCUPATION
1.
2.
3.
4.
5.

2.Contact details of Applicant:

Address
Post Code
Telephone number
Email Address

3.Reason for Application and Amount Requested: (Please attach copies of bills, estimates, etc, where appropriate)

FOR OFFICE USE
Date Received……………Known? Y/N……………Amount Date…………..Date Sent……….
Cheque No………………..Amount Agreed………………..Authorised by………………………

4. Other Sources of Support. e.g. Agencies and Grant MakingOrganisations, Crisis and Community Support Awards:( Please give details of other grant applications with their results, together with contributions by other family members)

5.Details of disabilities/Illness and their financial effects.

Show family memberInvolved.

6.Reasons for unusual household expenditure e.g. Maintenance payments, debts/arrears. Repayments, high fuel bills, special diets, payments for care, transport costs etc.

7.Accommodation:(Underline or highlight)

Owner occupied/private tenant/council/social housing/sheltered/residential/hostel.

8.Monthly Household Income after Deduction of Income Tax:(If more than3 incomes, please give details on a separate sheet)

Monthly Income / 1 / 2 / 3
Salary/Wage
Retirement Pension
Pension Credit
Occupational Pension
Income Support
Employment Support Allowance or Incapacity Benefit
War Pension
Attendance Allowance
Personal Independence Payment (PIP)or Disabled Living Allowance
Carers Allowance
Child Benefit
Maintenance Payments
Job Seekers Allowance
Housing Benefit
Council Tax Reduction Scheme
TOTAL

9.Total Monthly Household Income:

TOTAL

10.Monthly Payments:

Gross Monthly Payments / Amount
Rent / Mortgage
Ground Rent/Service Charges
Water Rates
Council Tax
Utilities e.g. Gas/Electricity/Phone
TOTAL

11.Details of Savings and why they are not available to

meet this request:

12. Anything you want to add to support the Application;

13. Source of Application:

The Hampstead Wells and Campden Trust will use the personal information about any individual contacts/referrers provided in this form and elsewhere to administer the application and monitoring process and any grant which is awarded.

Referrer’s Name
Job Title of Referrer
Organisation Name
Address
Email Address
Contact Number
Date of Application

14.Name of Payee/Address where cheques should be sent:

( The Trust cannot issue cheques directly to individual applicants – grants must be paid through an agency:)

Name of Payee
Address of Payee

Signature of applicant: ______

Please return the form to;

The Hampstead Wells & Campden Trust,

62 Rosslyn Hill, London, NW3 1ND

or

email:

Tel: 0207 4351570

Fax: 0207 435 1571

Website:

Company Limited by Guarantee No. 4541031 Registered Charity No. 1094611