Supported by:

SCOTTISH NAUTICAL WELFARE SOCIETY

937 Dumbarton Road, Glasgow G14 9UF

Tel: 0141 337 2632

Email:

GRANT APPLICATION FORM

If youhavedifficultycompleting theform pleasecontact theSociety.

1.Applicantdetails
Surname / Forenames
Address / NINumber
Dateofbirth
Placeofbirth
Telephone
Postcode / Single/married/ divorced/widowed/ partner
Lengthof timeat thisaddress:
Accommodationtype (houseflat etc): / Dateof marriage/
partnership
(ifapplicable)
Owneroccupier/rented/leased:
Nameoflandlord(whereapplicable): / Dateofdivorce
(ifapplicable)
Previous
addressif changed in last3years / Datespouse/
partnerdied
(ifapplicable)
Relationship to
personinsection4
Postcode
2.Particularsof spouse/partner
Surname / Forenames
Address
(ifdifferent from
applicant) / NINumber
Dateofbirth
Placeofbirth
Reasonforseparateaddress:
Postcode
3.Particularsof sonsanddaughters(includingadults) anddependants
Name / Age / Livingathome
oraway / Relationship
toapplicant / Current employment/
education/ trainingetcstatus
4a.Particularsof persononwhom eligibilityisbased
Surnamewhenserving / Dateofbirth
Forenames / Relationship toapplicant
Dateofdeath
(ifapplicable) / Causeofdeath
(ifapplicable)
Employmenthistory inMerchant
NavyorFishingFleet / Date joined / Date left / Reasonforleaving: Resignation, illness,injury, redundancy,other
Discharge BookNo: / Rank/ratingat endof service:
ServicedetailsverifiedYES/NO / Meansofverification:
Detailsofserviceinhostilewaters,whereapplicable(i.eintimeofwar/conflict):
DetailsofservicewithRNLI,whereapplicable:
4b.Detailsof otheremployment(including armedservices)
Nameofemployer / Natureofemployment / Dates / Typeofbusinessor trade union/tradeassociation
From / To
5.Detailsof employment of spouse/partner(includingarmedservices)
Nameofemployer / Natureofemployment / Dates / Typeofbusinessor trade union/tradeassociation
From / To

6. Stateof health

Areyouor anymembersofyourhouseholdchronically ill

orsufferingfromapermanentdisability YES/NO

7. Monthlyincomeandexpenditureof household
Monthlyincome / £ / Monthlyexpenditure / £ / Arrears
Payments
£
Earnings / Mortgage
Wages/salary(applicant) / Second Mortgage
Wages/salary(spouse/partner) / Rent(netofHousingBenefit
seeSection9)
Tax Credit / CouncilTax(net ofCouncil
Tax Benefit see Section9)
Maintenance/CSA receipts / Gas
Electricity
Pensions (applicant) / Water rates/sewagecharges
Occupational pension(s) / MagistratesCourt fines
StateRetirement Pension / Maintenance/ CSApayments
PensionCredit / Telephone
War DisablementPension / TV/Video/Satellite/Cable
StateWidow’sPensions/
BereavementAllowance / Groundrent/servicecharge
WarWidow’sPensions/AFFP
Pension / Buildings/contentsinsurance
Otherhousingcosts
Pensions (spouse/partner) / Mortgageendowment policy
Occupational pension(s) / LifeInsurance
StateRetirement Pension / Otherinsurance(s)
PensionCredit / Other fuel (incl oil, coal,bottled gas)
War DisablementPension / Pensioncontributions
StateWidow’sPensions/ BereavementAllowance / Carer/childcarecosts
WarWidow’sPensions/AFFP Pension / Housekeeping(inclfood, laundry,cleaning materials,
pocket moneyetc)
StateBenefits / Carcosts(inclinsurance,MOT, tax,runningcostsetc)
JSA/ESA/IS(applicant)
JSA/ESA/IS(spouse/partner) / Travel costs(incltaxisand
buses)
Disabilityrelatedbenefits –
specify / School meals/mealsatwork
Clothing
Prescriptions/healthcosts
Liabilities/debts
(from Section10)
Family/child relatedbenefits–
specify / Otherexpenditure-specify
Otherbenefits–specify
All otherincome(egsub-letting, contributionsfrom other household members, grantsfrom
other charities)–specify
TOTAL INCOME / TOTALEXPENDITURE

3

8.Savingsandcapital / £
Applicant’sandspouse/partner’stotal savings(incl capital,investments,building society,bank)
9.Statebenefits
HousingBenefit received / YES/NO
Council Tax Benefit received / YES/NO
Areenquiriesabout otherbenefitsbeing made?YES/NO IfYES,whichbenefits?
10.Liabilities/debts
(incl secured loans, unsecuredloans,HP, tradingagreements, loansfromfamilymembers)
Creditor / Dateof loan / Amount of loan
£ / Weekly instalments
£ / Total arrears ofinstalments
£ / Amount outstanding
£
11. Previousassistance(fromall charitablesources)
Date / Amount / Fund / Natureofassistance
12. Assistance required
Pleasesummarisetheassistancerequired. FurtherinformationmaybeprovidedatSection15, and copiesofrelevantinvoices,estimatesor quotesshouldbeenclosed.
Typeofassistance / Estimatedcost
£ / Contributionfrom clientand familymembers
13. Other fundsapproached
(Local,national,occupational etc, withamountsrequested/promised/receivedif known)
1 / 4
2 / 5
3 / 6

4

14. Declaration
• Ideclarethat the informationI havegiveninSection1-12 is, tothebest of myknowledge,correct.
•Iunderstandthat the informationI haveprovided will beused toprocess thisapplicationfor assistance.
•Iagreethat thedetailson thisform maybepassedinconfidencetoother agenciesandcharities, includingthe Seafarers’Adviceand InformationLine,in thecourseof thisapplication.
Signatureof applicant / Date
Signatureof applicant’sspouse/partner / Date

Forusebyindependent caseworker (if applicable)

15. Caseworker’s ReportRecommendations
Caseworkersareremindedof their responsibilitieswithregardtothe Data ProtectionAct1998
Amountrequired£
(continueonpage6ifnecessary)
Nameof caseworker (blockcapitals) / Signatureof caseworker
Date
Address / Telephone
Fax
Email
Postcode

(continuedfrom section15)

06/15