Application for Assistance Form

In Confidence

  1. Guidance notes for completing the form
    1. Personal Details
      The ‘applicant’ may be a person who has served in our industry, or their spouse/ partner/widow/widower/other family member
    2. About You and Your Family/Dependants
      There are numerous occupational charities that can be approached for additional grants and it is important to provide details of the nature and type of employment of all relevant parties (applicant/spouse/partner/family/dependant).
      Details are required of children/dependants, irrespective of their age, because of the financial impact they might have on the household if they are still living at home.
    3. Savings
      Savings can affect both entitlement to benefits and the way in which other charities view applications. All savings are taken into account when assessing need
    4. Debts
      Details of all outstanding debts must be included. If you have already sought advice, this should be included in the ‘other debt information’ box
    5. Family/Dependant Health Issues
      Refer to the details you have completed in Section 5 and highlight any illness or disability for any of those listed
    6. HM Armed Forces
      It is important that information regarding armed forces and related associations is included. This will provide helpful information if the need arises to approach other charities, specifically those dealing with the armed forces.
    7. Other Organisations Approached
      It is very important to complete this if you have or are receiving assistance from other charities or organisations, so that we do not approach them twice
    8. General Information
      Supply as much information about needs as possible. For costly items such as house repairs and electrically powered vehicles, we may need to approach other charities who will expect us to have established all known information. For most disability equipment we will be requesting medical evidence to support your request.
    9. Declaration
      It is a requirement of the GDPR that you understand why this declaration is necessary.
      The purpose of the declaration is to ensure you are satisfied that the information provided is correct and that you authorise the Electrical Industries Charity to approach other charities. If personal details of your spouse/partner are included, their consent should be obtained wherever possible before the form is returned to the charity.
    10. GDPR
      Please read this carefully before signing. It defines your rights as an individual in relation to the information held about you and how it may be used.
      In addition you are entitled, under the GDPR, to see the completed Application Form and related reports.
    11. Supporting Documents
      It is essential that as many of the following supporting documents as are relevant, are supplied with your application:
      • Letter(s) from the DWP regarding benefits/pensions/tax credits
      • 3 months occupational or private pension payslips
      • 3 months payslips
      • Full bank statements for 3 months for all accounts

      If application is for mobility or disability equipment or adaptations then it is likely that an Occupational Therapist report will be required and this can be discussed on receipt of the application.

      If you are applying for additional funding for mental health support please note you must provide 1 month’s bank statement.
    12. Assistance with this form
      Should you require any assistance in completing this form, please call the number on the accompanying letter or our Access Assistance Helpline on 0800 652 1618.

1 Name and Address

Please enter your last name
Please enter your firstname
Please make a selection
Please enter your address
Please enter your Postcode

1.1 Personal Details

Please add details
/ / Please enter your date of birth
Contact details
Please add details
Please add details
Please add details
Please check your email address
Spouse/Partner
Please enter your spouse's full name
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Next of Kin
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Please make a selection

1.2 Accommodation

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1.3 Employment history

Please include 5 years of employment history within the electrical and energy sector.

Please enter the applicants National Insurance Number
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If you qualify for help through your partner/spouse/husband please fill out the employment section here.

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Please enter the dependants name
/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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Applicant/Family/Dependent Health Issues - relating to this application

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1.6 HM Armed Forces

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Please enter a Service/Branch
Please enter the number
Please enter rank
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1.7 Other Organisations Approached

Please make a selection
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Please enter a Name of Association
Please enter a purpose
Please enter an outcome
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Please enter a Name of Association
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Please enter a Name of Association
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Please enter a Name of Association
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Please enter an outcome
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1.8 General Information

In this section please tell us the problem in which you need help, supplying us with as much information as possible. Consider the help you need and how you think we may be able to assist

Please enter the details

1.9 Income and Expenditure

Please ensure you add your Income per week

If field is mandatory (*) please input 0 if you do not recieve described fund

No. in family 1 2 3 4 5 6 7
Food & General 70.00 105.00 140.00 175.00 190.00 205.00 220.00
Clothing 10.00 20.00 30.00 40.00 50.00 60.00 70.00
Incidentals 20.00 28.00 36.00 44.00 52.00 60.00 68

Employment

Please only include numbers
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Other Income

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Other Charitable Funds

Please enter the source name
Please only include numbers

Service Pensions

Please only user numbers
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Retirement Pensions

Please only user numbers
Please only user numbers

Sickness Benefits

Please only include numbers
Please only user numbers
Please only user numbers

Bereavement Benefits

Please only include numbers
Please only user numbers

Disability Benefits

Please only user numbers
Please only user numbers
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Means Tested Benefits

Please only user numbers
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Please only user numbers
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Expenditure per week

If you have no costs please input 0

Residence

Please only user numbers
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Insurance

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Medical

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Household

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Car Expenses

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Fares

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Total sums of money in your...

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Total sums of money for your partner/spouse...

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2.1 Debts

Please select one
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As you have indicated that you have debts, please complete all relevant details using fields below.

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Other debt information

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2.2 GP Details (If you are applying for mental health support only)

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Supporting Documents

It is essential that as many of the following supporting documents as are relevant, are supplied with your application:

  • Letter(s) from the DWP regarding benefits/pensions/tax credits
  • 3 months occupational or private pension payslips
  • 3 months payslips
  • Full bank statements for 3 months for all accounts
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Declaration for All Applications

Please sign
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I agree to my information being shared between services.

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Please sign
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