CIMA Benevolent Fund

(registered charity 261114)

Please return the completed form to:

CIMA Benevolent Fund Secretary

CIMA

The Helicon

One South Place

London

EC2M 2RB

United Kingdom

PERSONAL DETAILS

Surname
First names
Address
postcode
Telephone / home
mobile
Email
Date of birth
Marital status

CIMA MEMBERSHIP

Name of member or former member
CIMA contact ID
If you are not the member, what is your relationship to the member ?
Is the member also a member of any other professional bodies ? Which?

FAMILY DETAILS: YOUR PARTNER

Name
Date of birth
Occupation
Membership of professional bodies

FAMILY DETAILS: YOUR CHILDREN AND OTHER DEPENDANTS

Name / Date of birth / Relationship to you / In full-time education or working ? / Living with you ?

YOUR EMPLOYMENT HISTORY

Current employer
Name
Address
Your job title
Date this employment started
Previous employers in last 10 years
Name / Your job title / Dates of this employment

YOUR PARTNER’S EMPLOYMENT HISTORY

Current employer
Name
Address
Job title
Date this employment started
Previous employers in last 10 years
Name / Job title / Dates of this employment

HEALTH

Please give details of any illness or disability relevant to your application.

APPLICATIONS TO OTHER CHARITIES

Please give details of any other charities to which you are applying or have applied.

Name of charity / Date of your application / Assistance received

YOUR HOUSEHOLD INCOME

Frequency (weekly, monthly, annual) / Yourself / Your partner / Office use only
Earnings
Pensions - private/occupational
state pension
Welfare benefits
Interest income
Dividends
Other investment income
Rents received
Help from children
Help from other family members
Help from friends
Help from other charities
Any other income (please specify)
LESS any tax you have to pay if any of the figures above are not net of tax
TOTAL

YOUR HOUSEHOLD EXPENDITURE

Frequency (weekly, monthly, annual) / Yourself / Your partner / Office use only
Rent
Mortgage
Care home fees
Service charges
Local taxes
Water charges
Gas
Electricity
Other fuel
Food and household goods
Home help / domestic care
Medical expenses
Clothing and footwear
Telephone/mobile/internet/TV
Pets
Motoring costs – tax
- insurance
- petrol
Other travel costs
Insurances – building and contents
- medical
- life
- other
Help to family members
Pension contributions
Debt servicing – bank loans
- credit cards
- other
Other regular expenditure (please specify)
TOTAL

YOUR CAPITAL

Please show the value of these assets. / Yourself / Your partner
Bank deposits
Shares
Bonds
Other savings
Owned property – main home
- other properties
Other (please specify)

YOUR DEBTS

Please show the amounts outstanding. / Yourself / Your partner
Mortgage
Bank loans
Credit cards
Arrears on household bills
Loans from family and friends
Other (please specify)

ADDITIONAL INFORMATION

Please provide any additional information in support of your application, such as any recent changes in your circumstances or changes which are about to occur.

CONSENT (To be signed by both you and your partner)

I/we declare that, to the best of my/our knowledge, the information provided above is accurate.

I/we consent to the processing by CIMA staff of the data I/we have provided on this form and in other communications with CIMAin compliance with the Data Protection Act 1998.I/we consent to the disclosure of the same data by CIMA staff to CIMA representatives, where necessary forpurposes of assessing my/our application for assistance, and to other charities and organisations who may be able to assist me/us. I/we further consent to the processing of the data by these representatives, charities and organisations.

Signed ……………………………….. (applicant)Date …………..

Signed ……………………………….. (applicant’s partner) Date …………..

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