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					                                                                                              RST 2009
                     ANGLICAN CHURCH OF SOUTHERN AFRICA

                APPLICATION FOR FINANCIAL ASSISTANCE FROM
               THE ROBERT SELBY TAYLOR WILL TRUST for 2009/10


NAME OF APPLICANT: ……………………………………………………………………………..

DIOCESE:                     ……………………………………………………………………………..

CATEGORY:             (Please mark with an X which is applicable)

                      A.     PENSION AUGMENTATION:
                             Answer questions 1 to 6 and 9, 10 & 11             ……

                      B.     EDUCATION:
                             Answer questions 1 to 6 and 7, 10 & 11             ……

                      C.     SICKNESS:
                             Answer questions 1 to 6 and 8, 10 & 11             ……

                      D.     SPECIAL NEED:
                             Answer questions 1 to 6 and 9, 10 & 11             ……

OBJECTIVES:

   To supplement the pensions of Clergy of the Anglican Church of Southern Africa (ACSA), who, on
    retirement, were serving within the borders of ACSA;

   To supplement the stipends of Clergy of ACSA, for assisting in the education or maintenance of their
    children, or to provide funds to pay the cost of sickness, or other special expenses, or to make
    advances for any other personal use.

IMPORTANT NOTE TO APPLICANTS & BISHOPS:

1. Applications for assistance MUST be completed in full and submitted for endorsement to the Bishop
   of the Diocese in which the Applicant is serving. N.B. BISHOPS TO COMPLETE CHECKLIST
   TO ENSURE ALL REQUIRED INFORMATION IS SUBMITTED BY APPLICANT (failure
   to complete may result in applications being rejected by the Trust).

2. The Bishop of the Diocese shall then send all applications direct to the Archbishop’s office at 20
   Bishopscourt Drive, Bishopscourt, Claremont, 7708, Cape Town, for consideration.

3. Whilst applications for Categories A, C and D may be submitted throughout the year, applications for
   EDUCATIONAL ASSISTANCE MUST be submitted to the Bishop of the Diocese and received at
   Bishopscourt :

                                      BEFORE 15 July 2009
                                                                                   RST 2009



                                                                                                  Page 2 of 8

    QUESTIONS 1 TO 5 TO BE COMPLETED BY ALL APPLICANTS

       CONTACT DETAILS

     (a)   Name of Applicant: …………………………………………………………………………

     (b)   Address: ………………………………………………………………………………………

           ………………………………………………………………………………………………….

     (c)   Telephone Nos. ………………………………………………………………………………..

     (d)   Fax No …………………………………………………………………………………………

     (e)   Email Address: ……………………………………………………………………………….

     (e)   Age:       …………………

     (f)   Single, Married, Divorced, Widow or Widower:      …………………………………….….

     (g) Year of retirement on pension (if applicable):    ………………………………………….


     (h) What is the gross amount of your ANNUAL earnings from whatever source (excluding
         house and/or transport allowances) this year?:
         PLEASE ATTACH COPY OF RECENT PAY/INCOME SLIP

           …………………………………………………………………………………………………

     (i)   If the amount given as your answer to 2(h)) above includes a pension, please specify
           the amount and from which pension fund/s it comes:

           …………………………………………………………………………………………………

     (j)   What is the gross amount of your spouse’s ANNUAL salary, and other income this
           year?
           …………………………………………………………………………………………………

     (k) Do you or your spouse own property or other assets
            in excess of R5 000 in value?                   ……………………………….
          IF ‘YES’, PLEASE GIVE FULL DETAILS AS AN ANNEXURE TO THIS APPLICATION

3.    What is your TOTAL Household Income? …………………………………………………….


4. What is the amount of assistance being asked for in this application?


       PLEASE STATE SPECIFIC AMOUNT REQUESTED ……………………………………
                                                                              RST 2009



                                                                                         Page 3 of 8



5. How many Children/Dependents rely on you for support?

      ………………………………………………………………………………………………….

      PLEASE GIVE THEIR NAMES & AGES AS AN ANNEXURE TO THIS APPLICATION.


6.   Are any of your children/dependents in receipt of any income or financial support? …….

      IF ‘YES’, PLEASE GIVE FULL DETAILS AS AN ANNEXURE TO THIS APPLICATION.
                                                                               RST 2009

                                                                                                Page 4 of 8


   QUESTION 7 FOR COMPLETION BY CATEGORY B: EDUCATION APPLICANTS ONLY


7. EDUCATION:

     (a) What will be the total cost of having your children at school or tertiary institutions next
         year without any assistance?


     ……………………………………………………………………………………………………

     (b) How much of this will you and your spouse, or other members of your family, be able to
         provide?

          ………………………………………………………………………………………………

     (c) How much of this will your Diocese provide?

             …………………………………………………………………………………


     (d) What other steps (if any) have been taken to fund these costs (e.g. part-time work, loans,
         bursaries etc)?


       …………………………………………………………………………………………………



                       PLEASE COMPLETE FORM ON PAGE 5
              IN RESPECT OF CHILDREN FOR WHOM YOU ARE APPLYING



                         PLEASE NOTE THAT FUNDING FOR
                  PRE-SCHOOL EDUCATION CANNOT BE CONSIDERED
                                                                                                                       RST 2009

                                                                                                                  Page 5 of 8


      QUESTION 7 (continued)

                                                 CHILDREN FOR WHOM YOU ARE APPLYING :

NAMES OF          AGE       STUDIES TO BE           ANNUAL       OTHER (give full       TOTAL   NAME OF SCHOOL,
CHILDREN                    UNDERTAKEN              FEES         details of                     COLLEGE,
                            (State which year)                   books,uniform,                 UNIVERSITY, ETC
                                                                 boarding, etc)




                 N.B.       PREVIOUS YEAR’S SCHOOL / TERTIARY RESULTS MUST ACCOMPANY THIS APPLICATION
                                                                                          RST 2009

                                                                                      Page 6 of 8


 QUESTION 8 TO BE COMPLETED BY CATEGORY C: SICKNESS APPLICANTS
  ONLY


8. SICKNESS:

  (a) Name of sick person and (if not applicant) relationship to applicant:

       …………………………………………………………………………………………………

  (b) How long has the person been sick (state in weeks, months or years):

       …………………………………………………………………………………………………

  (c) What is the nature of the sickness?

       …………………………………………………………………………………………………

  (d) PLEASE SUPPLY A MEDICAL CERTIFICATE IN SUPPORT OF YOUR ANSWERS
      TO 8 (b) AND 8 (c)

  (e) Please indicate whether you or your spouse receive assistance in meeting medical
      costs and, if so, provide the name of the Fund, your membership number and the amount
      already received in respect of the costs incurred through this particular sickness.

       …………………………………………………………………………………………………

       …………………………………………………………………………………………………
                                                                                    RST 2009

                                                                                               Page 7 of 8


   QUESTION 9 TO BE COMPLETED BY CATEGORIES A & D:

    PENSION AUGMENTATION AND SPECIAL NEED APPLICANTS ONLY

9. SPECIAL NEED AND/OR PENSION AUGMENTATION:

    Please give full details of the special need for which you are making application, including the
    amount of assistance or pension augmentation requested:

    ………………………………………………………………………………………………………

    ………………………………………………………………………………………………………

    ………………………………………………………………………………………………………


   QUESTIONS 10 AND 11 TO BE COMPLETED BY ALL APPLICANTS

10. State any other circumstances, if any, which would enable your application to be considered
    fully:

    ………………………………………………………………………………………………………

    ………………………………………………………………………………………………………

11. BANKING DETAILS:

    In the event of your application being successful, kindly supply your banking details, in order that
    your grant may be paid to you as speedily and securely as possible, in the form of a direct deposit
    into your account :

    Name of Bank:              ……………………………………….

    Branch Name:               ……………………………………….

    Branch Code:               ……………………………………….

    Name of Account:           ……………………………………….

    Account No:                        ………………………………………

    Account Type (Savings/ Cheque etc): ……………………..

    DECLARATION (to be completed by all Applicants)

    I declare that the statements made by me in this application are true in all respects:



    ………………………………………………..                                                      …………………
    Signature of Applicant                                                       Date
                                                                              RST 2009

                                                                                           Page 8 of 8


                                     REPORT BY BISHOP

Please give as much detail as possible about the applicant, to enable a fair assessment to be made.

Please also complete the attached Checklist to ensure that all required information is
included, to assist the Trust when considering the application.

This entire form (including the first page indicating the category of application) should be sent to
the Archbishop’s Office at Bishopscourt, Cape Town, when completed.




Diocese of ……………………………………………………………………………………….

Bishop’s Signature ………………………………………….

Date ………………………………………………………….
                                                                     RST 2009
                                   CHECKLIST


                                                                   Please
     PAGE NO.          REQUIREMENT (where applicable)              mark with
                                                                   X when
                                                                   complete
          1
    All Applicants   Name of Applicant
                     Name of Diocese
                     Category applied for
          2
    All Applicants   Applicant’s Name & Contact Details
                     Annual Earnings – Applicant / Spouse
                     (with supporting payslips)
                     Pension Details
                     Property/Assets Owned (with details
                     attached)
                     Total Household Income (with supporting
                     documents/payslips)
                     Amount of Assistance applied for
          3          No. of Children/Dependents (with names &
    All Applicants   ages attached)
                     Children/Dependents Support (with details
                     attached)
       4             Total Annual Education Costs, without
Education Only       assistance
                     Contribution from Family
                     Contribution from Diocese
                     Other Steps Taken to Fund Costs
      5              Children Applied For (names, age, name of
Education Only       educational institution, course year &
                     subject , total fees & other related costs)
                     Each Child’s Most Recent Exam Results
          6
    Sickness Only    Name of Sick Person & Relationship
                     To Applicant (if not applicant)
                     Nature & Length of Sickness (with
                     Medical Certificate attached)
                     Medical Aid details

7
     Pension /       Special Need/Pension details
    Special Need
       Only
                     Additional Information in Support of
                     Application (all categories)
                     Banking Details (in full)
                     Declaration – Signed & Dated by Applicant

          8          Bishop’s Report (please give as much detail
    All Applicants   as possible)
                     Bishop’s Signature & Date

				
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