Essential Grants Programme

Application Form

Applicant’s name *

Current full postal address of applicant *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

If the applicant is moving into a new home, please provide the full postal address and the date of moving if known

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date moving in

Phone number of applicant *

Email address of applicant *

Number of children in the family *

Ages of children in the family *

Number of adults in the family *

What is the item (or items) you need for your family ? If several items are needed, please PRIORITISE by listing in order of need *

Please provide a link to any specific items that can be purchased through Amazon/Argos etc, to help us understand what is required although we may source the item from elsewhere

(this is not necessary for any appliances)

School uniform / clothing

Items required and sizes for child 1

Please include sizes, girl or boy, quantity, school name and colour or house if necessary

School uniform / clothing

Items required and sizes for child 2

Please include sizes, girl or boy, quantity, school name and colour or house if necessary

School uniform / clothing

Items required and sizes for child 3

Please include sizes, girl or boy, quantity, school name and colour or house if necessary

is Other the

School uniform / clothing

Items required and sizes for child 4

Please include sizes, girl or boy, quantity, school name and colour or house if necessary

Using the applicant’s words, please tell us about the circumstances and how a grant will help the family. Please tell us how the child(ren)’s life will improve having this item(s). Using the applicant’s words will help the panel to better understand the family’s current situation and needs *

Referring agency *

Name of referee *

Contact number of referee *

(to be contacted if any queries)

Email address of referee *

Length of time the referee has known the applicant *

In what capacity does the referee know the applicant ? *

Are you working with other professional services ? If so, please tell us who ? *

Do you think there may be other benefits you might be eligible for but have not yet applied for (eg Kinship allowance or Special Guardian allowance) ? *

Using the referee’s words, is there anything else to add for the panel to consider? *

INCOME – monthly figures

Please provide income/expenditure details in order that CCSP can better assess the financial need of the family. We ask that the referee completes this section with the applicant. Details of all household income/expenditure need to be given, including any financial contributions made by any adult aged 18 or over.

Does the applicant receive PIP ? *

(This helps us to understand the family situation better)

Monthly take home pay including regular overtime/bonus.

Please include any partner’s income (multiply any weekly figure totals by 52 and divide by 12)

Universal Credit

Child Benefit

Statutory Sick Pay

DLA

Carer’s Allowance

Maintenance / Child Support

Any pension - pension credit, state retirement pension, former employment / private pension ?

What pension

Income received from other adult children who work

Other income

Savings / assets / shares / premium bonds

TOTAL INCOME *

EXPENDITURE – monthly figures

Monthly figures (multiply any weekly figure totals by 52 and divide by 12)

Shortfall between rent due and benefit paid

Mortgage (please specify if any arrears)

Water rates (please specify if any arrears)

Electricity and gas (please separate if both and specify if includes any arrears)

Council Tax (please specify if any arrears)

Phone – mobile and landline (please separate if both)

Broadband / TV licence

TV package / streaming services (eg Netflix, sky, prime, spotify)

Any loans

Food

Toiletries

Cleaning supplies

Prescriptions

School meals

Fuel / road tax

Public transport (eg taxis / bus fares)

Insurances (eg car / home / life / pet)

Hair and beauty

Subscriptions / memberships (eg hobbies for children, swimming lessons)

Other (please specify)

TOTAL EXPENDITURE *

OVERALL

Overall surplus *

Overall shortfall *

SIGNED applicant *

Clear Signature

SIGNED referee *

Clear Signature

All information supplied on this form will be kept confidentially and in accordance with the General Data Protection Regulation (GDPR). However, the Essential Grants Manager will share your information internally, with the panel of trustees, in order that a decision regarding the application can be made. We will only contact you for the purposes of this application, unless you consent otherwise. Please see our Privacy policy on our website for further information.

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