Industrial & Provident Society 16946R Faulkner House, 31 West Street, Wimborne, BH21 1JS THE FAULKNER FUND APPLICATION/REAPPLICATION FOR ASSISTANCE
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- Eleanore Todd
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1 Industrial & Provident Society 16946R Faulkner House, 31 West Street, Wimborne, BH21 1JS THE FAULKNER FUND APPLICATION/REAPPLICATION FOR ASSISTANCE Please complete this form in BLOCK CAPITALS and using BLACK INK. Any applications made that are not clearly written will not be considered. All required questions should be answered in full to enable the Faulkner Fund Panel to assess the degree of need and the amount of grant, for the support of the applicant. Tenant Applicants are requested to answer all questions Staff Applicants are requested to answer sections 1, 2, 6, 7 & 8 1. Application (Tenant and Staff applicants) Made by..... Living at (address).... Details of misfortune underlying this application and/or the reason for the application and intended use of The Faulkner Fund grant if awarded..... Particulars of applicant (a) Tenant or Member of Staff... occupation. normal income.. wife/partner s occupation... normal income.. lump sum redundancy payment (if applicable).. For Office Use Claim No Name... Ref No. Applied... Received at Head Office.. Page 1 of 5
2 2. Children (a) Particulars of dependant children:- Name Age School or other place of education Fees per term Annual amount of grants or other assistance received (b) Details of help already given by Faulkner Fund Financial Statement:- (Tenant only) (a) Income (before deduction of tax) from all sources (please give annual figures) Applicant s earnings. Wife/Partner s Income. Dividends and Interest Retirement Pension from previous employer. State Pension.. Widow s Pension or Widowed Mother s Allowance. Family Allowance(s). Social Security benefits: Please List Support contributions from children.. Education Awards. Other Charities awards.. Other sources of income if any (please specify)... During last 12 months Estimated for Next 12 months Page 2 of 5
3 (b) Expenditure Rent (after deduction of rebate. Council Tax (after deduction of discount) Water Charges Mortgage Interest and Repayments.. Loan Interest and Repayments. Insurance Premiums (other than for car) Heating and Lighting.. Hire Purchase Payments.. Food and Housekeeping Clothing Applicant Wife/Partner s... Children. School Fees (including extras) Travel (essential, not holiday) Income Tax.. National Health Insurance Telephone. TV Rental / License.. Car running expenses (including insurance).. Other necessary expenses : Please specify. During last 12 months Estimated for Next 12 months 4. Financial Assets (Tenant only) Balance in Bank Account(s)... Balance in Building Society Account(s)... Balance in National Saving s Bank.. Balance in other savings... Details of Investments (a separate statement may be attached) Description of Stock / Unit Trust etc Nominal Value Market Value Net Income per annum Page 3 of 5
4 Life Insurance: Amount of cover. on life of..(name) Secured value. Any other assets (other than house contents) Comprehensive list of all outstanding debts (Tenant only) Mortgage amount outstanding.. period remaining. Loans (give full details of how secured).. Bank overdrafts. Unpaid accounts (itemise below) Rent. Council Tax. Mortgage Repayments. Heating & Lighting. Water. Telephone.. Credit Cards (please list)... Other. Total Liabilities 6. Details of applications to other charities or professional bodies, with results Any other information relating to your application may be included here, or in a separate letter All the above information is true and accurate at the time of submission. Signed... Date... Page 4 of 5
5 Recommendation We, the undersigned members of the Faulkner Fund Panel, recommend that, in the light of the enclosed statement of the applicant s application, a grant of. be made to be used for the following purpose(s).. Purchase Item? Details of requirement. Money? - Cash - BAC s (Sort code/account no) - Vouchers - Cheque (made payable to) DATE SIGNED NAME DESTINATION There must be three signatures from The Faulkner Fund Panel East Boro Housing Trust is a Registered Charitable, Industrial & Provident Society Under the Industrial & Provident Societies Act 1965 No R Registered by the Homes & Communities Agency No L0519 National Housing Federation No. 533 Page 5 of 5
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