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Benevolent Fund Application

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					                          Benevolent Fund Application Form
Please complete the following sections in full:
Name                                            Department


Telephone number:                               Home address (if currently not at work)

Email address

Current Salary plus allowances                  Start Date


Are you living with a partner?                  Do you have dependent children under 18?

Yes/No                                          Yes/No

Does you partner work?                          If so, how old are they?

If so, how much does s/he earn per year?


Is there someone else who lives with you        Are you applying for a grant?
over 18 yrs old who is dependent on you?
(e.g. disabled child/elderly relative/student   Yes/No
over 18) Please specify.
                                                Amount requested: £
Yes/ No

If so, what is their relationship to you?       Are you applying for an interest free loan?

                                                Yes/No
If so, how old are they?
                                                Amount Requested: £

Are they dependent on you financially?          Proposed repayments of £        per month

Yes/No                                          Repayments to commence:              (month)


Documentary Evidence. The following information will assist the committee in assessing
your application:
                       Attached?
Current Bank Statement Yes/No
Loan Details           Yes/No
Credit Card Statement  Yes/No

Please attach any other information you think might be useful.

Have you approached a bank or building society for financial assistance? Yes/No

Please provide details including dates and outcome of the meeting.



Have you approached the Citizens Advice Bureau or similar organisation? Yes/No

Please provide details including dates and outcome of the meeting.
                                      Benevolent Fund Application Form

Monthly Budget Planner
Please complete the following budget planner. The committee cannot assess your
application without this.
TOTAL MONTHLY INCOME                           £
Child Benefit
Child Maintenance
Other welfare benefits
Loans applied for/received
Your earned income
Your partner’s income
Contributions from other adults in household
Other
TOTAL INCOME

TOTAL SAVINGS and INTEREST ON
INVESTMENTS

MONTHLY EXPENDITURE
Mortgage / Rent
Council Tax
Gas/Electicity/Water Rates
House/Contents Insurance
Shopping (Food, etc)
Child care
Life Insurance
Season Ticket/Transport
Clothing
Car Expenses
Loan(s) monthly repayment
Credit card(s) monthly repayment
Telephone
TV/Cable/Satellite
Other (please specify)




Total Expenditure


BALANCE (Income – Expenditure)
                          Benevolent Fund Application Form
Reason for application and supporting information (please
continue on a separate sheet as necessary):




Declaration
Please read the following carefully before signing. Please
note that your application form will not be considered unless
it is signed.
I declare that the above information is to the very best of my knowledge, true and accurate,
and gives a complete picture of my financial circumstances. I understand that my application
will be treated as confidential and the decision of the Benevolent Fund Committee is final and
not subject to appeal.

I agree to details of this application and any resulting grant or loan being recorded and
processed on paper and electronic files in accordance with the Data Protection Act.

Should your application for a loan be successful, if you leave the University before the
repayment is completed you will be required to notify the Secretary to the Benevolent Fund
and repay the outstanding balance before you leave. Unless agreed otherwise, the
outstanding balance will be recovered from your final salary payment and if this is insufficient,
by direct payment from you.

I have read and understood the above statements and confirm that I accept them.


Signed: ……………………………………………………………. Date: ……………………………


To be returned with all supporting documentation to:

Claude Rouschmeyer
Secretary to the Benevolent Fund
Organisational Development and Business Improvement Unit
Human Resources Directorate

Please mark your envelope ‘Personal – addressee only’