APPLICATION FORM

Please complete this application in full and include income and expenditure for the whole household.

Part 1

Applicants Name

Address

Age

Phone

Please list members of your family and/or others living with you, stating relationship and the age of any dependants:

Please give details of the illness causing the hardship.

What assistance do you require from The Rochdale Fund for Relief in Sickness?

How much money are you requesting from The Rochdale Fund for the Relief of Sickness? (Please provide estimates if possible)

Have you or any members of your family previously received a grant from this or any other charity? (Please give details)

Please give any other relevant information you can think of in support of your application.

How did you hear about Rochdale Fund for Relief in Sickness

Part 2

Please complete this section in full and include ALL household income and expenditure, not just the applicant's income.

Please note if you receive Housing Benefit or Council Tax Reduction, do also complete the amount you pay in rent and Council Tax columns to ensure the total income and expenditure figures are accurate to your circumstances.

Weekly Income (£)

Earnings

How much do you earn? State average weekly income OR average monthly income x12/52

Pensions

State Retirement Pension

Employers Pension

Widows and War Widows Pension

Any Other Pension

Pension Credits

Attendance Allowance

Benefits

Total received in Universal Credit, Tax Credit, ESA, JSA or Income Support

Total received in Housing Benefit, Council Tax Reduction

Total received in Statutory Sick Pay, DLA, PIP or Incapacity Benefit

Total received in Carers Allowance

Total received in Child Benefit, Maternity Allowance

Total received in Winter Fuel Payment

Total received in any other benefits

Weekly Expenditure (£)

Household Costs

Rent or Mortgage

Council Tax

Home Insurance

Gas, Electric, other heating costs

Water Rates

Household including food, clothes

Debt

Loan, HP, Credit Card Payments

Emergency Fund, Budgeting Loan Repayment

Entertainment Costs

TV Costs including provider e.g.Sky. and TV licence

Telephone or Mobile Phone Costs

Subscriptions e.g. Amazon, Spotify, magazines

Social activities including childrens activities

Travel Costs

Travel Costs including car, taxi, bus

Charities

Total given to charities / voluntary organisations

Charities

Total received from charities / voluntary organisations

Other Income

Maintenance Payments, Investments etc (Please state)

Maintenance Payments, Investments etc (Amount)

TOTAL INCOME

Other Expenditure

Maintenance, Child Support Payments

Other Expenditure (Please state)

Other Expenditure (Amount)

TOTAL EXPENDITURE

The information I have given above is to the best of my knowledge true and correct and I ask the Trustees to consider my application*

Applicants Signature

Select a date

Part 3

THIS PART OF THE FORM IS TO BE COMPLETED BY A PROFESSIONAL REFERENCE ONLY. All applications must be supported by a professional person such as a doctor, social worker or health visitor. PLEASE NOTE: We are unable to process an application without a reference and we are unable to request references on behalf of the applicant. Please state why you are supporting this application.

Name

Job Title

Contact Tel:

Signed

Organisation

Select a date

Please note that it may take several weeks to process your application particularly on amounts over £1000

Thank you for your patience.