Almshouses Application Form - Berkswell Charities

Step 1 of 13

First Applicant

Is this a Single or Joint application?(Required)

Single

Joint

Prefix(Required)

Full Name(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Telephone Number(Required)

Mobile Number(Required)

Email address

Time at this address(Required)

Tax Band(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Marital Status(Required)

Employment History

Please give details of your current occupation (if any) and brief details of your employment history.

Second Applicant

Prefix(Required)

Full Name(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Telephone Number(Required)

Mobile Number(Required)

Time at this address(Required)

Tax Band(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Marital Status(Required)

Employment History

Please give details of your current occupation (if any) and brief details of your employment history.

Section 2 - About your family

Next of kin name(Required)

Relationship(Required)

Children

Parent

Sibling

Other

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Telephone Number(Required)

Mobile Number(Required)

Section 3 - About your present home

Type of accommodation(Required)

(e.g. 3-bedroom house, 2 room flat):

Do you, or your spouse, own it?(Required)

Yes

What is its present estimated value?(Required)

Is there a mortgage outstanding on the property?(Required)

Yes

What is the outstanding mortgage?(Required)

If you do not own the property where you currently live, who does own this property?(Required)

Section 4 - Your income

To enable the trustees to assess your application, please provide the following information. This should include details of all sources of income and state how frequently you receive them, e.g. weekly, monthly or annually:

Pensions

Type/Name

Amount

Frequency

e.g. State retirement pension, Pension paid by a past employer, Private pension, Widow’s or Widower’s pension, Any other pension

Social Security benefit

Type/Name

Amount

Frequency

e.g. Pension Credit, Attendance Allowance, Universal Credit, Any other benefits

Employment or self-employment. Please explain type of employment and hours of work.

You are required to send evidence of earnings such as payslips or proof of earnings with your application. Uploading these files is in 'Section 12 - Supporting Documentation'.

Other Income

Type/Name

Amount

Frequency

e.g. Annuities, Bank Deposit Account, Building, Society Account, Investment, Renting property or land that you own, Grants from a charity, Financial assistance from a relative/friend, From a trust fund, Any other income – please give details

Section 5 - Your capital

Bank accounts

Name

Current balance

Building society accounts

Name

Current balance

Name

Current value

National Savings (e.g. National Savings Certificates)

Value

Unit trusts

Current value

Premium bonds

Amount held

Section 6 - Borrowing

Do you have any loans or other debts outstanding?

Debtor

Type

Amount

e.g. Credit cards, Overdrafts, Store Cards, Loans etc

Section 7 – About your Health and Social Factors

Are you able and willing to live independently and to look after yourself and your accommodation?(Required)

Yes

Please give details of any significant illnesses, injuries or operations during the last five years

Are you currently receiving treatment for any illness?(Required)

Yes

Please give details

Are there any other health or social factors that you would wish the trustees to take into consideration when assessing your application?(Required)

Yes

Please give details

GP practice(Required)

GP name

Address of your GP(Required)

Street Address Address Line 2 City Postcode

The charity may wish to write to your GP asking him to complete a medical certificate to enable your application to be considered further. If you are appointed as a resident and, at a later date, trustees become concerned about your health and/or your ability to continue to live independently they may need to obtain a further medical report.

Do you have a conviction which is not spent under the Rehabilitation of Offenders Act 1974?(Required)

Yes

Please give details

This information will be processed solely for the purposes of this application.

Do you have any County Court Judgments?(Required)

Yes

Please give details

Do you have a Disclosure and Barring Service (DBS) certificate?(Required)

Yes

Would you be willing to complete a DBS check?(Required)

Yes

Section 8 - Pets

Note animals are NOT allowed in the Almshouse Properties.

Do you have any pets or animals?(Required)

Yes

Please give details

Section 9 - Additional Information

Applicants should be aware that almshouses are intended to be a community where residents can live safely together. If you wish to make any other statements in support of your application and suitability for almshouse accommodation please use the space below.

Section 10 - Why you are in “need”?

Please set out to the Trustees of Berkswell Charities why you are in “need,” whether this be financial, social, health related or any other “need” of a charitable nature. Please provide as much detailed information as possible together with supporting evidence.

Section 11 – References

Please give the names and addresses of two responsible people (not relatives) who know you well and whom the charity may approach for a reference. If you are currently renting accommodation, one of the referees should be your current landlord. Please indicate how you know the referees.

Name 1(Required)

First

Address(Required)

Street Address Address Line 2 City Postcode

Name 2(Required)

First

Address(Required)

Street Address Address Line 2 City Postcode

Section 12 - Supporting Documentation

Please supply the following documents to support your application. The Trustees reserve the right to request further documentation to enable them to consider your application. If you are unable to attach files to the online form, please send the supporting documents to: The Clerk to The Trustees, "Stroma Broch", 52 Meeting House Lane, Balsall Common, Coventry, CV7 7FX Please note that not providing documentation can delay the process.

Copy photo identification, i.e. driving licence or passport.

Drop files here or