Grant Application Form

Part 1
A. Beneficiary Details (the person who will receive the grant)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Age:

Does anyone live with you?

B. Person making the application (if the beneficiary is unable to apply themselves)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Relationship to Beneficiary:

Part 2

A. What is it about your current health that merits a charitable grant?

Please list your medical conditions and tell us how they affect your daily life.

B. What is it about your financial circumstances that merits a charitable grant?

Please provide details of your financial circumstances.
Are you in receipt of means tested benefits (e.g. Universal Credit, Pension Credit, Housing Benefit, Council Tax Support, income-based Jobseeker’s Allowance, income-related Employment and Support Allowance, Cold Weather Payments)?
Do you only receive the state pension?
Do you have significant savings?
Are you, or your family, able to contribute to the cost of what you are requesting?

C. How much money are you requesting and what is the grant to be used for?

Please provide full details of the amount requested and what it will be used for.
If equipment is requested, include a full description and the costs of delivery and installation.
Please include any quotes you have received.
Let us know if your application is recommended by a clinician at Bungay Medical Centre or another specialist clinic.

D. Improvement to your daily life

What difference would the grant make to your life and your family’s life?
For example, what would you be able to do that you cannot do now?

E. Supporting Documents (optional)

Please upload any supporting documents that may help your application
(e.g. medical letters, quotes, or other relevant evidence).
Accepted file types: PDF, DOC, DOCX, JPG, PNG. Max file size: 5MB.

Declarations

I, the beneficiary, declare that:

1. I am not receiving funds for this purpose from another source.

2. I would not be able to fund this request from my own resources.

3. The evidence I have given in this grant application is factually correct.

Signed:

I confirm the above declaration