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The information provided throughout this application form will be provided to the Charity in strictest confidence and will not be disclosed to anyone other than a member of the Board of Trustees. Applicants are advised that failure to disclose any relevant information may not only prejudice their current application, it might also jeopardise their future position if information is revealed subsequent to their taking up occupation of an almshouse.

1. Personal Details

Name in Full

Present Contact Address & Postcode
Telephone Number

If less than 10 years in above address please list previous addresses
Date of Birth

Age

National Insurance Number

Last or Present Employer’s name and address
Name of Referee

Address of Referee

Relationship of Referee

Location

Sycamore

John Betts

either
Next of KIn (Please provide the details of your current Next of KIn)

2. Income and Resources – Potential Almshouse Occupant(s)

In order to assist the Board of Trustees determine the level of your need, it would be appreciated if you were able to complete the questions below:-Net Income Please answer all questions. Enter ‘NIL’ where appropriate

Pensions

	Amount per week
	Yourself	Spouse
SRP State Retirement Pension
SWP State Retirement Pension
INDD Industrial Injuries Disablement Benefit
WDP War Disablement Pension
WWP War Widow’s Pension
PMG Superannuation (pension from former employer)
LHWP Widow’s pension from Late Husband’s employer

Allowances

AALL Attendance Allowance
MALL Mobility Allowance
ICA Invalid Care Allowance
SDA Severe Disablement Allowance
DLA Disability Living Allowance

Benefits

Incapacity Benefit
Income Support
Housing Benefit
Council Tax Benefit

Other

MAIN Maintenance Received by Yourself
VOLF Voluntary or Charitable payments received
BINC Rental income from any property

MISC Any other income – give details

3. Savings and Capital

Please answer all questions. Enter ‘NIL’ where appropriate.

	Amount
	£ Yourself	£ Partner
Bank Accounts
Post Office Accounts
Building Society Accounts
National Savings Certificates (state date bought)
Premium Bonds
Redundancy Payment (if in the last 12 months)
Cash – this includes any cash held at home

Any other capital – give details
Stocks/shares/unit trusts (please give current value or state name of companies, and number of stocks/shares held
If you, or your partner, own property other than the one you live in please give details
Address
Value £

Mortgage £

4. Present Accommodation

Do you or your partner own your Present Accommodation?

Yes

If YES, what is the present estimated value of the property?

Please give a very simple description of the type of property you own
What are your intensions regarding this property if you are offered an almshouse?
How much money do you still need to repay on a mortgage associated with this property? If there is no mortgage on the property, please write ‘NONE’.

If NO i.e. you do not own property wherein you are dwelling, who does own this Property?
Is this person related to you in any way? If YES, what is the relationship?

5. Health Factors

Are there any specific medical reasons you wish to have considered, it is advantageous if your present GP was able to substantiate the need by writing to the Trustees independently.

6. Social Factors

Have you ever had any disputes with your neighbours? If yes please give details.
Has an ASBO ever been issued to you or anyone living with you? If yes please give details.

7. CERTIFICATION I certify that the details above are correct to the best of my knowledge and that this application is submitted in good faith, without any attempt to withhold information, or deceive the Board of Trustees of Hammersmith United Charities. I am aware that failure to disclose information might jeopardise my position both before and after any potential allocation of an almshouse residence for my use and I also agree that Hammersmith United Charities may use the above information to check my suitability.