Grant Application

1. APPLICANT – CONTACT DETAILS

Title
 
DOB
 
First name
 
Phone number
Surname
 
National Insurance
Address
 
Postcode
 
How many years has the applicant lived at this address?
If less than 2 years, please give thier previous address below.
No of years:
   
Previous Address
 
Postcode
 

2. AGENT – CONTACT DETAILS (REFERRING)

First name
 
Job Title
 
Surname
 
Department
 
Work Address
 
Employer
 
Work phone
 
Postcode
 
Mobile phone
Email
 

3. PREVIOUS GRANT FROM LIVERSAGE TRUST

Has the applicant ever received a grant before from the Trust?
 
If you have answered ‘yes’ to the last question, please tell us when it was and how much grant they received
 

4. NAMES AND AGES OF CHILDREN

Please give first name(s), last name, and age
Child 1
Age
Child 2
Age
Child 3
Age
Child 4
Age
Child 5
Age
Child 6
Age
Child 7
Age

5. HOUSEHOLD ITEMS REQUESTED

Please tell us why you fell the applicant needs our help:
 
Please list below, in priority order, the items you want us to help the applicant with.:
Total cost should not exceed £150 – except as indicated in Advice to Agents’ sheet.
Priority
Description of item (See Advice to Agents’ sheet for list of eligible items)
Fixed Cost £ (See Advice to Agents’ sheet)
Priority 1
 
Priority 2
Priority 3
Priority 4

6. HOUSEHOLD FINANCES

Include the income and expenditure of everyone living in the household
Do the applicant receive Disability Living Allowance or Personal Independence Payment?
 
Does the applicant receive Attendance Allowance?
 
Income
Weekly average £
Income from Work after Deductions
Working Tax Credit
Universal Credit
Income Support
Jobseeker’s Allowance
State Pension and Pension Credit
Help received towards Rent and Council Tax
Employment and Support Allowance
Help received for children eg Child Benefit/Child Tax Credit/Child Support
Other Income 1
Other Income 2
Other Income 3
Savings
Does the applicant have any savings?
If yes, please tell us what they are and how much they have
 

7. OTHER GRANT APPLICATIONS

Has the applicant applied to any other organisations for a loan or a grant?
 
If you have answered ‘yes’ to the question, please tell us how much you have requested, what response you have had to the request and list the organisations:

8. JOINT DECLARATION OF MAIN APPLICANT AND AGENT

I declare that I have understood all the questions that Liversage Trust has asked and that that the information contained in the form is correct. I also understand that the Liversage Trust is legally required to verify the personal circumstances of applicants for charitable grants. I declare that we are not related by family and that we do not have a personal relationship.
I declare that if this application is successful, only the items as stated in this form and approved by the Trust will be obtained and I undertake to provide the Trust with receipts for all items purchased. I further understand that the Trust reserves the right to verify that the grant has been applied in the way intended, if necessary, by making an appointment to visit the applicant’s home.
I understand that any deliberately false statement or omission of material facts may result in action being taken against me.
For the purposes of the Data Protection Act 1998, I consent to the information contained in this form, and any information received by or on behalf of Liversage Trust relating to this grant application, being stored on the Trust’s computer with a paper copy of the summary in a manual file, for the sole purpose of grant processing, analysis and accounting. The Trust will treat all information in the strictest confidence and will not divulge it without the prior agreement of all concerned.
I also give permission for my details to be shared with other third parties, where necessary, for the purpose of determining a Grant award through the Liversage Trust.
Confirm Declaration
 
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