Online Application for a One-off Grant

"*" indicates required fields

1Introduction

2Preliminary Questions

3YOUR Details

4YOUR Health

5YOUR Situation

6Financial Situation

7Letter of Support

8Declaration

One-off Grant Application Form

1. Introduction

PLEASE READ THE FOLLOWING CAREFULLY BEFORE YOU START

We give financial support and assistance to adults who are unable to work because of a medical condition that is permanent or likely to be permanent or is potentially life-limiting.

To be considered for assistance you must meet all of these conditions:

Have a qualifying medical condition
Have been in paid employment but no longer able to work
Be living at home
Live in the EH postcode area
Be under State Pension Age (currently 66)
Be solely or mainly reliant on benefits.

More detailed information on eligibility and conditions for help is available is available here

If you wish to apply for assistance, please read the information here and complete the attached the following application form, giving as much information as possible

The application form must be accompanied by a letter of support from your social worker, healthcare professional or support worker.

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2. Preliminary Questions

IMPORTANT NOTE: TO QUALIFY FOR HELP UNDER THE SOCIETY’S RULES YOU MUST BE ABLE TO ANSWER YES TO ALL OF THESE QUESTIONS

Please answer Yes or No to the following questions:

Have you had paid employment?

Yes

Are you unable to work because of your medical condition?

Yes

Do you live in your own home or with a spouse, partner or other family member?

Yes

Is that home in the EH postcode area?

Yes

Are you under State Pension Age (currently 66)?

Yes

3. Your Details – Personal

Please give us following details about yourself:

Title

First Name

Initials

Last Name

Date of birth*

DD slash MM slash YYYY

Address*

Town / City

Post Code

Address Line 1

Address Line 2

How long at this address?

How many years

Telephone*

Mobile Phone

Home Number

example@example.com

Your Details - Health

NOTE: WE CAN ONLY CONSIDER APPLICATIONS FROM PEOPLE WITH A MEDICAL CONDITION THAT IS PERMANENT OR LIKELY TO BE PERMANENT OR IS POTENTIALLY LIFE-LIMITING. READ MORE HERE

Medical Condition*

(Illness or Disability)

When did this start?

How many years ago?

How does this effect you?

Medication(s)

What prescribed medication do you take for your medical condition?

Name of GP

Provide the name of your regular Doctor

Name and address of GP’s Practice

GP’s Telephone Number

Are there any other professionals involved in your care: e.g. consultant, specialist nurse

Yes

Please provide details of these other professionals.

5. Your Situation

PREVIOUS EMPLOYMENT

Most recent job

Name of employer

Address of employer

How long did you work there?

Date last worked

Reason for leaving

LIVING CIRCUMSTANCES

Please tell us who you live with

Full name

Date of Birth

MM slash DD slash YYYY

Relationship to you

Status

In employment, in education, retired, etc.

YOUR HOME

Type of accommodation

Owner occupier

Mortgaged

Private Rented

Council / Housing Association

House

Flat

Maisonette

Other

Hostel

Sheltered Accommodation

Residential Home

Nursing Home

please select all that apply

6. Financial Situation

NOTE: WE CAN ONLY CONSIDER APPLICATIONS FROM PEOPLE BE SOLELY OR MAINLY RELIANT ON BENEFITS

FINANCIAL SITUATION

NOTE: Please give all amounts below as weekly equivalents

Income

PIP/DLA/ADP

ESA/JSA

Housing benefit

Child benefit

Occupational Pension

Any other pension

Interest/Dividends

on investments including bank and building society interest

Any other income

subletting, boarders, other charities, etc.

Partner’s gross earnings

excluding allowance for expenses or car allowance

Partner’s gross income

from investments or savings

Any other income

Expenditure

Rent less rebate

Mortgage repayment

Council tax

Heating/ energy costs

Repayments of debts / loans

Other expenditure

e.g., child care

Savings

Balances with bank and building society accounts

Investments

Savings of Spouse/Partner

Balances with bank and building society accounts

Investments

PREVIOUS APPLICATION

Have you applied before?

Yes

Previous application details

Please tell us about any change in circumstances since previous application.

Please explain why you are seeking a grant*

If you wish, please use this space give us any additional information you would like to tell us about, for example any special needs or costs you may have because of your condition.

How did you hear about us?

7. Letter of Support

PLEASE UPLOAD ALL DOCUMENTS YOU WANT INCLUDE IN YOUR APPLICATION

PLEASE ATTACH ALL DOCUMENTS YOU WANT INCLUDE IN YOUR APPLICATION

DOCUMENTS

Drop files here or

Accepted file types: docx, doc, pdf, jpg, png, Max. file size: 10 MB.

8. Declaration - Send Application

PLEASE CONFIRM AND SIGN BEFORE SUBMITTING YOUR APPLICATION.

Privacy Notice

The Society takes your privacy very seriously and has a policy that explains why and how we will store, process and secure the information you give to us.

View our privacy policy.

Declaration*

I confirm

I confirm that the information given above is correct to the best of my knowledge and I agree that the Society may make such enquiries as are necessary including contacting my GP and my last employer. I understand that the information on this form will be used to assist the Society in proceeding with this application and I hereby give consent to its use for that purpose. In particular, I authorize my doctor(s) to give such information in support of this application as may be requested by the Society’s Doctor. I undertake to advise the Society of any improvements in my circumstances and of any change in my address.

I confirm that by submitting this application and signing this declaration I agree to the information on the form (and any attachment) being stored in the Society’s manual filing systems and computer systems for the sole purpose of grant processing, analysis, monitoring and accounting.

Declaration

I confirm that by submitting this application and signing this declaration I agree to the information on the form (and any attachment) being stored in the Society’s manual filing systems and computer systems for the sole purpose of grant processing, analysis, monitoring and accounting.

Signature of Applicant

Date

MM slash DD slash YYYY

Is the form is being signed by someone on your behalf, please provide details below?

Yes

Name

Relationship to applicant

Address

Telephone number

Signature

Date

MM slash DD slash YYYY

Online Application for a One-off Grant

One-off Grant Application Form

1. Introduction

2. Preliminary Questions

3. Your Details – Personal

Your Details - Health

5. Your Situation

PREVIOUS EMPLOYMENT

LIVING CIRCUMSTANCES

YOUR HOME

6. Financial Situation

FINANCIAL SITUATION

PREVIOUS APPLICATION

7. Letter of Support

8. Declaration - Send Application

Declaration

Registered Office