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1a Henrietta Place

London W1G 0LZ

Tel: 020 7549 1400

Fax: 020 7490 1269

Charity No. 213128

Date as postmark

Applications for financial assistance – for community nurses

In order to avoid disappointment, please ensure that you fit the criteria below before completing the form:

The Queen’s Nursing Institute is able to consider applications from NMC registered nurses who are in financial difficulty following illness, disability or other life trauma, and have worked or work in the community rather than in hospitals, for a minimum of 3 years.

Please give full details of your community nursing work.

If you do meet this criterion, please complete and return the application form along with the required supporting documentation:

  1. Copies of all bank statements covering the last full month
  2. Pay slip or pension advice, and/or notification of state benefits being received
  3. Evidence of community nursing

PLEASE RETURN COMPLETED FORM TO:
FREEPOST PLUS RTHS-LYYE-LCJZ
The Queen’s Nursing Institute
1a Henrietta Place
London W1G 0LZ

CONFIDENTIAL

REGISTERED CHARITY NO. 213128

The Queen’s Nursing Institute

1a Henrietta Place, London W1G 0LZ

Telephone: 020 7549 1400 Fax: 020 7490 1269

Your Details

1.Surname / Forenames
2.Address
Post Code Tel Number
Mobile Email address
3.Married /Civil Partnership / Single / Widowed / Divorced / Separated (please indicate)
4. Date of Birth / If married or widowed MAIDEN NAME
5.Are you registered disabled?
YES NO APPLIED / Are you registered blind?
YES NO APPLIED
6. Qualifications: / Status / Qualification gained / Date obtained
NMC PIN Number: / Current/lapsed/suspended

7.Employment History

Dates / Post Held / Employer
Date of Last Employment / Reason for leaving (retirement, ill health, redundancy etc)
Please give details of your community nursing work:
8.Please give a brief statement about your health. Continue on separate sheet if necessary (We may ask for a medical statement or certificate from your doctor.)
  1. Do you live in a nursing or residential home? (please specify)
  1. Details of your property: (house, flat, mobile home etc)
  1. Conditions of tenure (Owner/occupier, Leasehold, Rented)

12.Do you live alone or share accommodation? If shared, please give details of those living at home or contributing to household costs

Name / Date of Birth / Relationship / Payment to household

13.Reason for application and details of help required. Please enclose estimates or any quotes obtained. Continue on separate sheet if necessary

15. Have you applied to other charities?

Please name any other charities that you have approached or have had assistance from in the past two years and the amount received. We routinely exchange information with many other charities in our field
Name of charity / Amount awarded / Single or regular grant
Pls give the date of award

16.Details of Capital Resources

Bank Balances:
Current Account£………………………………………………… (Please send copy of latest statements)
Deposit Accounts£……………………………………………….. “
Post Office£………………………………………………. “
Savings£……………………………………………….. “
Building Society£……………………………………………….
National Savings£……………………………………………….
Premium Bonds£……………………………………………….
Rents from properties/Investments or other assets £…………………………………………
………….……………………………..

17.Details of MONTHLY INCOME

YouSpouse/Partner
£per month £per month / Office use only
Earnings (after tax) …….………… ………………
State Retirement Pension ……...... ………………
Occupational Pension …….…………………………
Universal Credit……………….……………….
Employment Support Allowance…….………… ………………
Statutory Sick Pay…….………… ………………
Pension Tax credit …….………… ………………
Working Tax credit…….………… ………………
Child Tax credit…….………… ………………
Child Benefit…….………… ………………
Attendance Allowance…….………… ………………
Job Seekers Allowance…….………… ………………
Disability Living Allowance/PIP: Care: ….………….. .…………….
Mobility:………………. ………………
Incapacity Benefit…….………… ………………
Industrial Injuries Benefit………………. ………………
Carers Allowance…….………… ………………
Family Income Supplement…….………… ………………
Income Support…….………… ………………
Housing Benefit…….………… ………………
Council Tax Benefit…….………… ………………
Regular Grants from charities…….………… ………………
Annuities…………………. …………………
Maintenance / Child Support…………………. …………………
Rents from property …..……….. ……………
Any other income (pls specify)…….………… ..……………

17a. Please enclose a copy of a recent payslip.

If you are in receipt of any Social Security Benefits, don’t forget to enclose a copy of the Department of Work and Pensions letter showing amounts being received.

18. Details of MONTHLY EXPENDITURE

Amount
£per month / Arrears
£per month / Office use only
Mortgage or Rent / ……………… / ……………… / ……………..
Endowment / Mortgage insurance / ……………… / ……………… / ……………..
Ground charges /Maintenance charges/ Service Charges / ……………… / ……………… / ……………..
Nursing/Residential Home Fee / ……………… / ……………… / ……………..
Home help/ home care /
Cleaner / …………….. / …………….. / ……………..
Child care costs / …………….. / ……………… / ……………….
Council Tax / ……………… / ……………… / ……………..
Food / …………….. / ……………… / ……………..
Gas / ………….… / ……………… / ……………..
Electricity / …………… / ……………… / ……………..
Telephone including mobiles / …………… / ……………… / ……………..
Water Rates / …………… / ……………… / ……………..
Car Insurance / …………… / ………….… / ……………..
Car Tax / …………… / …………… / ……………..
Petrol / ……………. / ……………. / ………………
House contents insurance / …………… / …………… / ……………..
Buildings insurance / ………….. / ………….. / ………………
Televisionlicence / …………… / …………… / ……………..
Television and/or internet tv packages / ……………. / …………… / ………………
Nurse Registration Fee / …………… / …………… / ……………..
Other (please specify) / …………… / …………… / ……………..
………..…. / …………… / ……………..
Liabilities and Debts eg loans or credit cards / Monthly Repayment / Amount outstanding
…………………… / ………………………… / ……………..
………………….. / ……………………….. / ……………..
………………….. / ……………………….. / ………………

Please note that non essential expenditure will not be taken into consideration when assessing an application

19.How did you hear about the Queen’s Nursing Institute?

I hereby certify that the information contained within this document is a true record of my current situation. Information given falsely or deliberately withheld will invalidate the application and no payment will be made, or if already in payment, stopped.

I understand that all information provided by myself or someone acting on my behalf will form a manual and computer file both of which are registered under the Data Protection Act.

For verification purposes I understand that The Queen’s Nursing Institute may contact the Department of Work and Pensions, NMC, Local Authorities or my GP to confirm information stated on this form. In some instances the QNI may also request that a letter of referral be supplied to support the application.

Unless an objection is supplied in writing, information contained within this form may be shared with other charities in order to try to secure the help I require, and to protect the funds of the QNI.

20.Your SignatureDate

***HAVE YOU ENCLOSED COPIES OF YOUR BANK STATEMENTS / PAY SLIP / NOTICE OF STATE BENEFITS?***

If the form has been completed by someone other than the beneficiary, please sign below stating your name and relationship to the beneficiary.

SignedDate

NameRelationship

PLEASE RETURN TO:

FREEPOST PLUS RTHS-LYYE-LCJZ

The Queen’s Nursing Institute

1a Henrietta Place

London W1G 0LZ

From time to time the QNI uses details of applications in completely anonymised form for general fundraising purposes and to continue our welfare work. All names and personal details are changed to ensure complete anonymity. Please tick box if you do not wish for your application to be used in this way. / 

THE QUEEN’S NURSING INSTITUTE

Monitoring Form

CONFIDENTIAL

This form is used to gather information for the purposes of monitoring adherence to our equal opportunities policy only. Information will not be used for any other purpose.

Personal data
Please indicate your age group: / 16-18 / 19-20 / 21-24 / 24-59 / 60+
Decline to say
Are you / Male / Female
Disability
Do you consider yourself to have a disability? / YES/NO / Decline to say
Ethnicity
White / Mixed
British / White and Black Caribbean
Irish / White and Black African
Any other white background / White and Asian
Any other mixed background
Asian or Asian British / Black or Black British
Indian / Caribbean
Pakistani / African
Bangladeshi / Any other Black background
Any other Asian background
Chinese or other ethnic group / Any other
Declined to say

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