Application for Grant Assistance Form (Individuals)

If there is any other information you think we should know in support of your application please email it directly to jabethell@lichfieldmunicipal.org.uk

Please click on our meeting dates page to find out when you will know if your application is successful.

Whom do I contact if I need help with the form or further information?

Please telephone the Trust’s administrator, Mrs Jane Bethell on 07546 966964, who will either help or refer the query to the Clerk. She is available each Monday to Thursday between 9.00am and 5.30pm.

Please complete the online form below:

APPLICATION FOR ASSISTANCE (INDIVIDUALS) 2025

Please fill in this form as fully and clearly as possible.

Name(Required)

Prefix First Last

Mobile Phone

Home Phone

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Address(Required)

Street Address City County Post Code

When did you move here?

Why did you move here?

Please list everyone else who lives with you at this address (partner, children, any other)

Please click on the + button to add new entries

Name

Date of Birth

Relationship to you

Who owns your home?

I do

Bromford

Midland Heart

Private Landlord

Other

Are you employed?

Yes

If YES, what is your job?

What assistance are you asking for? Please be precise and tell us the likely cost if you know it.(Required)

Have you applied to other Charities for financial assistance?

Yes

If YES, what was the result?

What else have you done to raise the funds yourself?

What, if anything, have you received from Lichfield Municipal Charities in the last three years?

Trustee Visits

Before the Trustees consider your request, someone from the Charity will need to visit you at your home.

If you are not at home when we call, and you have not already told our administrator that you will be out, we will not consider your application and you will be asked to re-apply later.

Please check our meeting/application dates page for more information

We cannot make appointments by telephone. To arrange for our visit please choose 3 days when you will be at home.

Please look at the meeting dates page .

Pick 3 days when you are at home

Please select 3 days when you are available.

Monday

Tuesday

Wednesday

Thursday

Friday

Please choose 3 hour period on each of 3 days when you will be at home (for example Monday 9:00 – 12:00, Wednesday 9:00 – 12:00, Friday 2:00 – 5:00) ALL DOGS MUST BE SECURELY LOCKED AWAY OTHERWISE TRUSTEES WILL TERMINATE THEIR VISIT AND YOU WILL HAVE TO REAPPLY.

Monday From Time

Hours

Minutes

Monday To Time

Hours

Minutes

Tuesday From Time

Hours

Minutes

Tuesday To Time

Hours

Minutes

Wednesday From Time

Hours

Minutes

Wednesday To Time

Hours

Minutes

Thursday From Time

Hours

Minutes

Thursday To Time

Hours

Minutes

Friday From Time

Hours

Minutes

Friday To Time

Hours

Minutes

INCOME

Wages (£) per month

Pension (£) per month

Housing Benefit (£) per month

Other benefits (Income Support, ESA, JSA, Maternity/Child Benefit etc.) (£) per month

Disability related benefits (PIP, DLA, AA etc.) (£) per month

Working Family/Child Credits (£) per month

Council Tax benefit (£) per month

Other Amount (please describe)

Other Amount (£) per month

Total PER MONTH

OUTGOINGS

Mortgage/Rent (£) per month

Council Tax (£) per month

Electricity (£) per month

Gas (£) per month

Telephone / mobile phone (£) per month

Food (£) per month

Clothes & shoes (£) per month

Insurances (£) per month

Travel (£) per month

Hire purchase, catalogue clubs etc (£) per month

TV licence, rental, package (£) per month

Other (please explain)

Other (£) per month

Total PER MONTH

Consent

Please read these important notes and conditions before you give consent.

If there is any other information you think we should know in support of your application please fill in the box below:

Consent(Required)

Lichfield Municipal Charities can only help residents of the City of Lichfield who are suffering genuine hardship. The Trustees will only consider applications from people who have already sought help from relevant agencies.

Electrical goods and carpets are supplied new but other goods may be good quality second hand.

Completed application forms are kept securely by the Clerk to the Trustees for one year and then destroyed.

The Trustees reserve the right to visit you up to a year after provision of help, to ensure that items are being used and maintained correctly.

If the Trustees discover that any information you have given is deliberately incorrect they reserve the right to:
(a) withdraw any offer of assistance
(b) require the repayment of any grant made
(c) refuse to consider any future application from you

The Trustees may wish to check the information you have given on this form, and if they think that another charity may be able to assist, or you have approached other organisations, they may wish to consult them.

I authorise Lichfield Municipal Charities to disclose such information contained in this form as may be reasonably necessary to enable verification and I agree to information on this form being disclosed to other charities or bodies in the circumstances outlined above.

I will reimburse Lichfield Municipal Charities in respect of any amount over and above that given to me in the event of funds being received from another source. I will notify Lichfield Municipal Charities if the help asked for in this application is received from any other source prior to this application being considered by the Trustees, whereupon this application shall be treated as withdrawn.

I understand and accept that as a condition of a grant being made to me, Lichfield Municipal Charities may disclose the fact of such grant to any other charity within the City of Lichfield, but only after such grant has been agreed upon.

I confirm that the information I have given is correct and that I have read and understand these conditions.

I agree

Date

DD slash MM slash YYYY