Fund Application – Emmaus Rd

If you are in need of financial help please complete the application form below.

Ideally all applications should be supported by a professional referrer who knows your circumstances (for example Citizens Advice, Family Support Worker, Home School Link worker, Health visitor, Housing Support Officer). Contact details of the referrer should be included on the application as we may need to contact them to discuss your application.

If you are applying as an individual without a referrer, we may ask you to speak to our Community Money Advice team before we process your application.

Generally we will pay suppliers directly for any awards given. All awards are discretionary, and each application will be considered subject to qualifying criteria.

APPLICANT DETAILS

Full name

Phone number

Email address *

Home Address *

Postcode *

How many adults and children are in the household?* *

REFERRER DETAILS:

Name of referrer

Referrer title

Phone number

Email address

How did you hear about us? How did you hear about us?

Are you or your spouse in full-time employment?

SOME MORE INFORMATION ABOUT WHY YOU NEED OUR HELP

What specific item or need are you applying for? * *

What is the estimated cost?* *

What other charities have you contacted regarding this?* *

Please outline your current financial situation with as much detail as possible to support your application. Include income and outgoings/ benefits received and the main reasons you need the grant?* *

Name of person completing this form

Phone number of person completing this form

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