Application For Discretionary Charitable Gift

In accordance with the Charity Scheme dated 29 December 1978, as subsequently amended, the Coventry Freemen’s Charity is able to award a discretionary charitable gift to help with a specific need. This can be made either directly to the applicant or alternatively to other charities or organisations working to prevent or relieve poverty or financial hardship who are proposing to assist the applicant. In each case, this is subject to the qualifying criteria set out below being met. The Charity is also able to award a discretionary annual benefit payment (payable in quarterly instalments and subject to periodic review) to assist with relief in need. If you wish to apply for the discretionary annual benefit payment, then an alternative application form should be requested from the Clerks’ office – contact details below.

It is part of the Trustees responsibilities to ensure that applicants for financial assistance are suitably qualified under the terms of the Charity’s governing document and it is necessary therefore for the Trustees to investigate the personal circumstances of all applicants.

Data Protection Statement

The Charity complies with the regulations for data security under the General Data Protection Regulations (GDPR) and the data we collect is classified as ‘personal data’ under Article 9 of the GDPR. We have procedures and policies in place to protect the collection and storage of this data. The personal data supplied on this form and other information relating to an application will be held on file. Some details may be checked with relevant organisations as the Charity reserves the right to investigate and verify personal information provided on this application but no details will be disclosed for any inappropriate purpose. You may have access to your personal information on request.

The Charity will maintain personal details on computer record and completion of this application confirms your agreement to this.

Supporting Documentation

All applications must be accompanied by proof of income and current address, plus a copy of the birth certificate and a copy of the relevant Freeman’s Oath.

Application Form

Charitable gift application

Criteria for eligibility

I am applying as:

Freeman/Woman of Coventry

Widow/Widower of a deceased Freeman/Woman

Dependant of a Freeman/Woman or deceased Freeman/Woman

Date of admission to Freedom

Trade to which apprenticed

Full name of Freeman/Woman

His/Her Trade

Relationship or dependency

His/Her date of admission

Date of death

General Details

Full name

Address

Date of birth

What date did you move into this address?

Phone

Please state who lives with you

Name

Relationship to you

Age

Add person Remove

Residential Status

Do you live at your address as

Owner Occupier

Tenant

Lodger

OtherOther

Your Financial Details – assets, monthly income and expenditure

Please provide the information requested in respect of the WHOLE household – this must include that of any co-habitee, live in-wife, husband or partner. Please state the monthly amount.

Amount earned each month from employment (net of tax)

Investment income, pension/benefits received each month (net of tax)

Total income each month (net of tax)

Average monthly household expenditure

Amount left at end of month

How much do you have in savings/investments

Assets/Liabilities

Please provide full details to include approximate value of investments or amounts owed ignoring the value of your residence if you are a home owner.

Additional Information

Please provide any other information which you consider helpful in support of your application. Where applicable a letter from your support worker, GP, health visitor, district nurse etc. will assist the trustees when considering your application.

Other applications for support

Have you applied for or received assistance from any other organisation or individual – please provide full details.

Please Note

The Charity is unable to give any personal tax or general financial advice and wish to point out that if you are in receipt of the Scheme Benefit you may wish to satisfy yourself with regard to your ongoing entitlement to receive any other current benefits and/or your personal tax position – it is recommended that if this is of potential concern to you then you should take appropriate independent advice.

Declaration

I declare that the foregoing statements made by me are correct to the best of my knowledge and belief. I authorise the Trustees of the Coventry Freemen’s Charity to make any enquires deemed necessary in support of my application and consent to the disclosure of any information provided by me to other charities and/or parties who may be contacted in the course of such enquiries. I consent to this application form being kept on file so that the trustees can keep in contact with me as needed.

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