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CONFIDENTIAL Powered By Docstoc
					                                                   4th Floor, Furniture Makers Hall, 12 Austin Friars, London EC2N 2HE
                                                                               Tel: 020 7256 5954 Fax: 0207 7256 6035
                                                                           welfare@fi-trust.co.uk www.fi-trust.co.uk

                              CONFIDENTIAL APPLICATION FOR ASSISTANCE
                                              Issued by FIT on 24/07/2011
  Please complete all sections in full to enable FIT to process your application for assistance. We need to ask for some
  personal information about your health, income, expenditure, your employment (including proof). Please complete the
  application in full. (Note you may be asked to provide proof of your employment within the UK furnishing industry, or
  medical evidence if needed). Remember, the more details you provide, the easier it will be to make a decision on your
  application. PLEASE COMPLETE IN BLOCK CAPITALS LETTERS – THANK YOU.

First Names                                                      Surname

Address:

Postcode

Telephone/Mobile Number

Email address:

Date of Birth                          Age                                 Martial Status

Do you suffer from a permanent disability or suffer from any illness? Please give details




Employment History from School Age to Date or to Retirement Age (Please list employment dates all employers, full
postal addresses including town and nature of business that you have been employed with). This section must be
complete in full) Should you require extra space please use the back of this page. Include your job title and any proof
of employment.




In what capacity were/are you employed in the UK Furnishing Industry?

Total Number of years you were/are employed in the UK Furnishing Industry?

Have you ever contributed to FIT? If so in what way? (if so give Registration Number & Details)

Were you in the Services Air Force/Army/Navy etc?


                                                             1
Where was your partner employed/dates/role etc?


How did you hear about FIT?

If you found us by researching on the Internet we would love to know how you found FIT website?

                                                       Weekly Income

Please give details of your current weekly income. All sources of your partner’s income must be declared.
Wages                                                                                Self                 Partner


State Benefits – please give full details of any state benefits you receive or
are waiting to receive:
State Pension

Income Support

Attendance Allowance

Incapacity Benefits, Sick Pay

Disability Living Allowance

Housing Benefit

FIT Annuity

Occupational Pension(s)

Child Benefit

Working Family Tax Credits

Other Income

Other Charities Annuities etc

                                                                       Totals (A)                (B)
                                                                              £                  £
                                                                       Total Weekly Income (A+B) £


Savings (please provide full details)                                            Self               Partner

Current Account/Deposit Bank Account

Building Society

Stocks and Shares

PEPs/ISAs

National Savings




                                                                2
                                                   Weekly Expenditure
Please give details of your current weekly expenditure. Again, if you prefer to provide monthly or annual figures, then please
make it clear you are doing so. Your partner’s expenditure should be included.
Rent or Mortgage                                                                £

Council Tax                                                                    £

Water Rates/Sewage Charge                                                      £

Insurance premiums (Property, Contents, Life)                                  £

Television (Rental and, or Licence)                                            £

Gas/Electricity/ Oil/Coal/Calor Gas etc                                        £

Telephone/Mobile Phone                                                         £

Hire Purchase (Please give details start and end date)                         £

Loan Agreements (Please give details start and end date)                       £

Mail Order (Please give details start and end date)                            £

Car & Travel Costs (taxis, trains, buses etc)                                  £

Special Dietary or Medical Expenses (Please give details)                      £

Household Expenses (food, laundry, toiletries, newspapers etc)                 £

Arrears (Please state details)                                                 £

Others (i.e. Gardener, Chiropodist, Window Cleaner etc)                        £

Clothing/Footwear

Vet Bills/Pet Insurance etc


                              HOUSING
What type of accommodation do you live in? (House/Bungalow etc.)

Do you own the property?

If yes, please state current valuation and outstanding mortgage

If you are in receipt of Housing Benefit, please state amount




                                                                  3
To help FIT process your application form we need you to provide a brief description of your current
circumstances. (How did you come to be in financial difficulty? How can FIT help? What do you want from us?).
The more information that you provide the easier it is for FIT to process your application. Remember to include
quotes etc.




                                                       4
 Please do not just tick the relevant boxes below.


I wish to apply for: PLEASE DO NOT LEAVE                       PURPOSE FOR WHICH GRANT IS SOUGHT
THIS BOX BLANK
                                                           £
Regular Weekly Grant.

                                                           £
Special One off Grant for (please state details) Provide
documentation if you have them i.e. quotes/estimates
and how much you are applying for.




                                                           £
A UK Holiday (please provide details such as the full
postal address where you wish to take your holiday.
All holidays must not be booked in advance or paid for
until your application is presented to our Grants &
Welfare Committee. No holidays grants are paid to
individuals.
(Please note the maximum grant is £300.00 per
person). Along with the names of your
partner/family (for children please state ages).



                                                           £
Television Rental and or Licence Payment (renewal
Date of next TV Licence payment…………………..)

                                                           £
Have you approached other charities for funding if so
who and how much have they granted you?




 To the best of my knowledge and belief, I the undersigned, declare that the particulars given are true and
 accurate statement of my current circumstances.

 Signed:                                         Date:


 If a third party had completed this form, please state relationship to application.


 Signed:                                         Relationship:

 Date:



 Contact Address or Telephone Number.

                                                               5
                    AUTHORISATION AND DATA PROTECTION ACT
                        Please read this section very carefully

In order for FIT to be able to process your application, It has been necessary for us to ask you for personal
information, such as health, finance and background. The Data Protection Act is in place to make sure that
organisations do not misuse such information. To comply with the Act, FIT needs to have your explicit
consent to hold such information, either in manual or computer files.

Please be assured that your details will not be used for marketing purposes. The information is treated as
strictly confidential and is made available to appropriate personnel with FIT, and in particular the Benefits
Department of FIT and FIT Benefits Committee. The information will only be used in connection with your
application for assistance.

PLEASE READ AND TICK THE RELEVANT BOXES

1) I have enclosed proof of my employment with the UK Furnishing Industry, payslip, letter from employer
etc.    (Photocopies will be taken by the FIT and the originals returned back).

       Yes              No

 2) I authorise the FIT – Furnishing Trades Benevolent Association to contact
       my present employers within the UK Furnishing Industry to confirm my employment.

        Yes           No
If you can't provide relevant information on your employment with the UK Furnishing            Industry
please request a HM REVENUE & CUSTOMS REQUEST HARDSHIP FORM.

      Yes

  3) I authorise the FIT – Furnishing Trades Benevolent Association to
        Approach other charities on my behalf

       Yes              No

   4) I authorise my GP to give information required by the FIT
        In order to facilitate my request for assistance

       Yes              No

   5) I authorise FIT – Furnishing Trades Benevolent Association
        to contact my social worker or sponsor in order to facilitate my
        request for assistance

       Yes              No

    6) I agree that FIT may hold and process personal data (including sensitive
        personal data) about me in its manual and computer files. I understand I may
        update or modify the information at any time.

       The FIT may wish to use your case for publicity purposes. If so names will be changed
       to protect your identity.


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



                                                   6

				
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