St Albans Old People’s Trust

Charity No. 222522

Individual Application

In the first instance pleasecall for an initial discussion prior to submitting an application. Telephone: 07541 659442.

Return Completed Form to: St Albans Old Peoples Trust, C/O CVS St Albans, Civic Centre, St Peters Street, St Albans AL1 3JE or email :

All information will be kept private and confidential

Section A – Support Worker/Contact Details

Please complete this section if you are applying on behalf of someone else

Name:
Connection to Applicant:
Organisation:
Job Title:
Address:
Contact Phone Number(s):
Email Address:

Section B – Details of person to benefit from grant

Name (first and surname):
Date of Birth:
Address:
Contact Phone Number(s):
Email Address:
How did you hear about the Trust?

Your Circumstances - Please give us details on the following. The more information you provide the quicker we can make a decision.

Living…(delete as applicable) / Alone With Others
Home…(delete as applicable) / Rented Council Housing Association Owned
Work (what you used to work as, how long for, when you retired):
Disability or Ill Health (yourself or your partner)
Incidents (accidents or problems that you have encountered recently)
Debts and Hardship (how you are coping financially):
Other information (e.g. nearby relatives, problems with home, any other issues)

Section C – Household Benefits, Income and Savings

Are you in receipt of…? (Please delete as applicable)

Amount if know
Pension Credits or Guaranteed Credit / Yes No
Savings Credit / Yes No
Housing Benefit / Yes No
Council Tax Benefit / Yes No
Disability Benefits / Yes No

Please give an idea of how much you receive from the following:

Private Pension (own – per month) / £
Private Pension (partners per month) / £
State Pension / £
Other Income (benefits, credits etc.)
Total Household Income: / £
Total Household Savings: / £

Section D- What the funding is requested for:

Please confirm what you are requesting from the Trust…
Do you have a quote? / Yes/No (If yes please enclose)
Have you approached the NHS, Council or Social Services for help? / Yes /No (please detail)