1. SURNAME
(Block letters)

FORE NAME(S)

2. PERMANENT ADDRESS

POST CODE

TEL NO

3. DATE OF BIRTH

(Attach copy of Birth Certificate if possible)

4. Email Address (If you have one):

5. How long have you been employed in the Leather and Hide industry?
(A widow(er) should give details of his/her spouse or civil partner’s employment in the industry).
Please give as much information as possible.

6. Are you

Married
Widowed
Single

If you are married, please give:

Fore name of
spouse/civil partner

Date of birth of
spouse/civil partner

If you are a widow/widower,
please give:

First name of your late husband/wife/civil partner

Date of his/her death

7. Do any relatives live with you
(children/parents)?

Yes
No

If Yes, please give details (name and date of birth of any children, details of any contributions they make to household expenses)

8. WEEKLY EXPENDITURE

b) COUNCIL TAX (after deducting any benefit)

c) MORTGAGE PAYMENT

d) Any other major regular expenses
(not including food/clothing)

9. WEEKLY INCOME

b) War Disability Pension

c) Incapacity Benefit

d) Severe Disability Allowance

    – Care:

    – Mobility

e) Disability Living Allowance

f) Attendance Allowance:

g) PENSION CREDIT

h) Jobseeker’s Allowance

i) Housing Benefit

Yes
No

j) Council Tax Benefit

Yes
No

k) Pension from employer

l) Full or part-time employment

m) Regular payments from:

    a. Relatives:

    b. Other charities:

    n. Any other regular income.
e.g. from investments etc. (please give details)

APPLICABLE ONLY TO THOSE IN NURSING/RESIDENTIAL HOME

11. INCOME

Local Authority payment towards fees

per week

Other income*

per week

Total Weekly Income

per week

* Please give details of “Other income”

EXPENSES

Nursing/Residential Home fees

per week

Other regular expenses

per week

Total Weekly Expenses

per week

ASSETS AND LIABILITIES

The possession of property or other assets will not necessarily prevent assistance being given but it is essential that full knowledge of such assets should be made available to enable the Committee fully to appreciate your circumstances.

12a. ASSETS

Do you or your spouse/civil partner own the house in which you live?

If YES, please state estimated market value:

i)  Date of purchase

ii) Amount of mortgage outstanding:

iii) Period left to run (years)

12b. CASH IN HAND OR IN BANK/BUILDING SOCIETIES

i) Cash in hand (if in excess of £250) or in Bank or Building Society current account

ii) Post Office Account

Iii) Bank/Building Society Savings Account

iv) Savings Certificates

v) Any other investments (please give details)

13. LIABILITIES

Have you any major outstanding debts?

If YES, please give details

14. Are you making this application on account of:

–  Ill Health

Yes
No

–  Hardship

Yes
No

In the case of ill health, please state:

Nature of disability:

Name and Address of your GP:

Do we have your permission to refer to your GP if necessary?

DECLARATION

I DECLARE THE INFORMATION GIVEN ON THIS FORM TO BE COMPLETE AND ACCURATE.

Usual signature of applicant:

Date:

Witness signature
(not a relative to the above)

Name and Address of
Witness

Occupation