Farnham Support Fund Application

Section 1

Name*

Date of Birth*

Address*

Postcode*

Telephone (Home)*

Mobile

Email*

Section 2

Your application will need to be supported by a referee such as a headteacher, GP, social worker, health visitor or the CAB. Your referee will be contacted to verify your application. Please complete their details below. Unfortunately, we cannot consider any applications that do not include this information.

Referrer's Name*

Referrer's Occupation*

Referrer's Contact No.*

Today's Date*

Section 3

Assistance Required*

food/foodbank
support with fuel debt
household equipment
wheelchairs
care alarms
bed and beddings
other

Reason for the application*

Upload Documents

Drop files here or

Max. file size: 4 MB, Max. files: 5.

Please upload any supporting documents that could help assist us with your application. This could be a copy of any bills, debts, receipts, invoices, or any other relevant documentation.

Section 4

Household finances (give details that you feel are relevant)

Total weekly income £*

Weekly Expenditure £*

If you received State Benefits, please state which

Number of adults at this address*

Number of pensioners at this address*

Please give details

Number of children at this address*

Please give the ages of the children

Number of registered disabled persons at this address*

Please give details

Are you receiving help from other local charities/organisations?*

Yes
No

If Yes, please give details

Section 5

Applicant's Name*

Date*

By ticking this box you agree that the information given is correct*

Please Tick

Please tick the box below to confirm that you agree to us collecting, using, storing and sharing your personal information in accordance with the Farnham Town Council Privacy Policy*

I Agree

Guidance Notes - You must Read These and Click 'Confirm'

Section 1

The applicant should complete this section in full giving full name, address and telephone numbers. An email address is also preferred for contact purposes.

Section 2

Applications are generally not considered unless they are supported by a referee. This could be a Social Worker, GP, Social Services, Home School Link Worker, Head Teacher, Health Visitor, Nurse or applicable Voluntary Organisation. The referee should know about the applicant’s situation and be able to verify the details.

A covering letter/email must accompany the application. The referee should state their name and occupation and provide a telephone number for contact purposes. The Farnham Coronavirus Support Fund may contact the referee to verify details. You are requested to confirm that you agree to the Support Fund processing your details and data in accordance with our privacy policy.

Section 3

It is important to state the type of assistance required. We would expect some effort to be made with regards to size and type of any goods required as well as their estimated costs. For example, if support with fuel bills are requested then we would expect details of these.

The second part of this section requires a clear description of the need for the application. This may require details of household or financial circumstances including health issues to support the application. Your application may be shared confidentially with the Citizen’s Advice Bureau, Farnham Money Advice, Farnham Foodbank, or another local organisation we think can assist help you.

Section 4

Please detail any relevant household financial details including weekly income and expenditure, whether the applicant receives State benefits, and the household details including the number of adults and dependent children. It is important that details of what support has been received or requested from other charities / organisation is included.

Section 5

The applicant needs to sign and date this section and confirm that all the details are correct. You are requested to confirm that you agree to the Support Fund collecting, using, storing and sharing your personal information in accordance with our privacy policy. It will only be used in connection with this application and kept confidentially.

I have read the above guidance notes*

Confirm

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