Essential Grants Programme

Reference Form

Reference allocated

Referring Agency *

Person applying for a grant *

Name of referee *

Address of referee/supporting agency:

Address Line 1 *

Address Line 2

Post Town/City *

County *

Post Code *

Address of referee/supporting agency: *

Telephone number: *

Email address: *

How long have you known the applicant? *

In what capacity do you know the applicant? *

Please outline the circumstances that you think should be taken into account when making a decision about the grant the applicant has applied for. Please be as detailed as possible, and if you have assisted the applicant with the application form, try and cover circumstances not given in the application in order for the panel to best understand the families need. *

Would you be happy for the Society to contact you if any further clarification is needed? *

All information supplied on this form and the accompanying application form will be kept confidentially and in accordance with the General Data Protection Regulation (GDPR). However, the grant administrator will share your information internally, with The Board of Trustee Directors, in order that a decision regarding the outcome of the application may 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.

INCOME

Please provide income/expenditure details in order that CCSP can better assess the financial need of the family. We ask that the referee fill this section out 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.

Dropdown

Take-home pay inc. regular overtime or bonus

Partner’s take-home pay inc. regular overtime or bonus *

Universal Credit

Child Benefit

Child Tax Credit

Working Tax Credit

JSA/ESA

Statutory Sick Pay

DLA

PIP

Carer’s Allowance

Maintenance/Child Support

Pension Credit

State Retirement Pension

Former employment/Private Pension(s)

Other (Please Specify)

Income received by you from other members of the household

Savings/assets/shares

EXPENDITURE

Shortfall between rent due and benefit paid *

Mortgage (if including arrears specify amount) *

Water Rates (if including arrears specify amount)

Electricity (If including arrears specify amount)

Credit known allocated

Gas (If including arrears specify amount)

Council Tax (If including arrears specify amount)

Telephone (landline)

Telephone (Mobile inc. length of contract)

Secured Loans

Food

Toiletries

Cleaning Supplies

School Meals

Prescriptions

Maintenance/Child Support Agency

Other (e.g., memberships/subscriptions/hair & beauty/luxuries)

Holidays

TOTAL

Overall surplus:

Overall shortfall:

SIGNED [Applicant] *

All information supplied on this form and accompanying application form will be kept confidentially and in accordance with the General Data Protection Regulation (GDPR). However, the grant administrator will share your information internally, with The Board of Trustee Directors, in order that a decision regarding the application to the EGP 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.