Grant and Benefit Review Form

GRANT AND BENEFIT REVIEW FORM
Full Name
Address	Date of Birth
	Age
	Marital Status
County	Postcode

Telephone area code and number

Occupation or previous occupation

Date of registration
As blind	As partially sighted

Additional health problems or disabilities:


Members of Household
Do you have a partner living with you? Yes No
If Yes, please give details below
Name	Relationship	Date of Birth


Do you have any dependant children?
(Those aged under 16, or aged 16-17 and in full-time education) If so, please give details below
Name	Relationship	Date of Birth






Are there any other members of the household? If so, please give details below
Name	Relationship	Date of Birth




Whole Household's Income and Savings

How much is received each week	Beneficiary	Beneficiary's Partner	Other Household Members
Net earnings from work (plus number of hours)	£	£	£
State Pension	£	£	£
Occupational Pension	£	£	£
Income Support	£	£	£
Job Seekers Allowance (Income based)	£	£	£
Job Seekers Allowance (Contribution based)	£	£	£
Child Benefit	£	£	£
Invalid Care Allowance	£	£	£
Incapacity Benefit	£	£	£
Severe Disablement Allowance	£	£	£
Family Credit	£	£	£
Any other income not shown elsewhere	£	£	£
Total of above	£	£	£
Pension Credit	£	£	£
Attendance Allowance	£	£	£
Disability Living Allowance Care	£	£	£
Savings(if none write ‘none’)	£	£	£


Is any member of the household the owner occupier of the property?		Yes No
If Yes go on to part 2		If No go on to part 3

Part 2
Is there a monthly mortgage payment?		Yes No
How much is the monthly mortgage payment?
Is any of this amount met by the Benefits Agency (please state amount)

Part 3
Rented accommodation:
Do you rent from:	The local Council
	A Housing Association
	A private landlord
	(please tick one of the above)

Weekly rent before Housing Benefit is deducted
(Do not include water rates, heating or service charges)

Rent actually paid

Do you live in residential accommodation, Please tell us the weekly fees payable

Council tax/Northern Ireland rates
Gross council tax/rates
Do you receive any discount or benefit (please state amount if known)
Amount paid per year after any deductions

Please tell us how we can help
Annual Grant	One-off payment
One-off payment (please specify the item and amount and attach a quotation)
Please enter name of person to whom cheque should be payable if the grant is approved:-

Supporting Statement STATEMENT OF OFFICIAL supporting the application. This applicant is known to me and I recommend that the grant be made for the following reasons (use separate sheet if required):


Name		Signature
Organisation represented
Address		Position


County		Postcode
Telephone Number

Signature of applicant Date

To enable the Trustees of The Royal Blind Society identify those blind and partially sighted people in need of financial help we would appreciate to know how you heard of the Royal Blind Society?