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The Scottish Welfare Fund - Application Form

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1 THE SCOTTISH WELFARE FUND – APPLICATION FORM
APPLICATION FORM
ABOUT CRISIS GRANTS AND COMMUNITY CARE GRANTS
Who can get a Crisis Grant or a Community Care Grant?
You may be able to get a Crisis Grant or Community Care Grant if you are getting one
of these benefits:
• IncomeSupport
• incomebasedJobseeker’sAllowance
• incomerelatedEmploymentandSupportAllowance
• anytypeofPensionCredit.
YoumayalsobeabletogetaCommunityCareGrantifyouarelikelytogetoneof
thesebenetswhenyouleavecare,suchasahospital,acarehomeoraprison.Ifyou
arenotononeofthesebenets,buthavenowheretoturninacrisis,theCouncilmay
decidetomakeanexceptionandawardyouaCrisisGrant,butthiswouldbeunusual.
ACommunityCareGrantoraCrisisGrantmaybegoodsoritems,vouchersorcash.
How we decide whether we will give you a grant
Adecisionmakerwilllookatalltheinformationonyourapplicationbeforedecidingif
wecanmakeagrant.Thereisonlyalimitedamountofmoneyavailableforpayments
anditemssowecannotmakeagrantineverycase.
Theinformationyougiveusontheformwillhelpusdecide:
• ifyouqualifyforapaymentoritems,andifso
• whetherwecanmakeagrantfromthemoneywehaveinthebudgetandwhatthe
awardshouldbe.
Youneedtogiveusasmuchinformationasyoucanabouthowagrantwouldhelp
you,eithertocopewithacrisisortoliveindependentlyinthecommunity.Wewill
usethisinformationtodecidewhetherornotwecangiveyouagrant.Ifyoudonot
giveustheinformationweaskforintheform,wewillnotbeabletogiveyouagrant.
Wewillchecksomeoftheinformationyougiveus,forexamplethebenetsyouare
on,withDWP.Wemayalsotalktootherpeopleaboutyourapplication,forexample
socialworkersordoctors.Wewillonlymakeagrantorgiveyouitemsifwearesure
thatthisistheonlywaythatyoucangetthehelpyouneed.Wemayalsodecideto
giveyoulessthanyouhaveaskedfor.
2 THE SCOTTISH WELFARE FUND – APPLICATION FORM
How a Crisis Grant can help
ACrisisGrantistohelpsomeonepayforthethingstheyneedtopreventharmto
theirortheirfamily’shealthorsafetybecauseofanemergencyordisaster.
What you should not apply for:
YoushouldnotapplyforaCrisisGrantifyouhave:
• othermoneythatyoucanuseforthethingsyouneed
• alreadyhadthreeCrisisGrantsorawardsmadetoyouinthelast12months.This
doesnotincludeSocialFundapplicationsbeforeApril2013
•appliedforaCrisisGrantforthesamethingswithinthelast28daysandnothing
haschanged.
How a Community Care Grant can help
ACommunityCareGrantistohelpapersonwiththingstheyneedtolive
independentlyinthecommunityratherthanhavingtoliveincare.Thiscouldbe
becausetheyare:
• settingupinthecommunityafteraperiodincare
• wanttostayinthecommunityratherthanhavingtogointocare
• takingpartinaplannedre-settlementprogrammeafteranunsettledwayoflife
• afamilyfacingexceptionalpressure,forexamplebecauseoffamilybreakdown,and
needhelptoprovideasafeandsecureenvironmentfortheirchildren
• caringforaprisoneroryoungoffenderonreleaseontemporarylicence.
CrisisGrantsandCommunityCareGrantsdonothavetobepaidback.
What you should not apply for:
YoushouldnotapplyforaCommunityCareGrantifyou:
• havesavingsof£700ormoreandyouareunderpensionage,orsavingsof£1200
ormoreandyouareoverpensionage.YourapplicationforaCommunityCareGrant
willnotbesuccessfulunlessthereisareasonwhyyoucannotusethesesavings
• areincare,arenotleavingcarewithin8weeksorhavenotbeenincarefor
3monthsormore
• haveappliedforaCommunityCareGrantforthesamethingswithinthelast
28daysandnothinghaschanged.
Help from other sources
TheDWPisstillprovidingBudgetingLoansormaybeabletogiveyouashort-term
AdvanceonBenet.Ifyoudon’tthinkyouwouldgetaCrisisorCommunityCareGrant
orbenetsfromtheDWPbutstillneedhelp,aCitizensAdviceBureau,yourCouncilor
alocalwelfarerightsorganisationmayalsobeabletoofferyouadvice.Youcannd
yourlocalCitizensAdviceBureauinthephonebookoratthiswebsite:
www.cas.org.uk/bureaux. Youcanndoutmoreaboutlocalwelfarerights
organisationsontheRightsAdviceScotlandwebsiteatwww.rascot.co.uk.
THE SCOTTISH WELFARE FUND – APPLICATION FORM 3
FILLING IN THE FORM
What you will need to fill in this form:
• yourNationalInsurancenumber
• detailsofmoneyyoureceive
• contactdetailsforpeoplewhoarehelpingyouwhotheCouncilmaywanttocontact
• informationtoprovethatyouarewhoyousayyouare,and
• otherdocumentsthatgiveinformationaboutyoursituation,suchasthepolice
incidentnumberifyouhavereportedacrime.
If you need help to fill in the form
Thisformshouldbelledinbythepersonmakingtheapplication.Ifyouneedhelpto
llinthisform,youcanasksomeoneelsesuchasafriendorrelative,oryoucan
contactyourlocalCouncilorCitizensAdviceBureau.Youstillneedtosignthe
declarationatPart6yourself.
Applying on behalf of someone else
Ifyouareapplyingonbehalfofsomeoneelsewhoisunabletollintheform,you
shouldcompletetherelevantpartofsection6andaskthemtosignthesectionwhich
authorisesyoutoapplyontheirbehalf.Wewillthendealwithyouinfuture.You
shouldcompletetheformwiththedetailsofthepersonyouareactingfor.
About the form:
Thisformisinsixsections:
Part1. Generalinformationaboutyouandyourfamily
Part2. Aboutmoneyyouhaveandreceive
Part3. Whattypeofgrantyouareapplyingforandwhy
3a–CrisisGrantinaDisaster
3b–CrisisGrantinanEmergency
3c–CommunityCareGrant
Part4.Otherinformationthatwillhelpustomakeadecision
Part5. Aboutothersupportyoureceiveormightwanttoreceive
Part6. Declarationandwhathappensnext
YoushouldllinParts1,2,4,5and6.YoushouldalsocompletethesectionofPart3
whichisaboutthegrantyouareapplyingfor.Pleasecompletetheforminblackink.
Ifyouneedextraspace,pleaseusetheblankpageatthebeginningofthisform.
Receipts
IfyouareawardedaCrisisGrantorCommunityCareGrantyoumaybeaskedto
providereceiptstoshowyouhaveboughttheitemsyourgrantwasawardedfor.
Pleasemakesureyoukeepyourreceipts.
Review
Ifyoudonotagreewiththedecisionmadeonyourapplication,youcanaskfora
review.Detailsofwhotocontactareattheendofthisform.
Making Your Application
Simplest and quickest way to make your application is by telephone.
For more information or to make an application please call 0131 270 5600.
More information is also available at www.midlothian.gov.uk/scottishwelfarefund
Completed application forms should be returned:
by post to: in person to:
Midlothian Council Midlothian Council
Buccleuch House Buccleuch House
PO Box 12956 1 White Hart Street
Dalkeith Dalkeith
Midlothian Midlothian
EH22 1YB EH22 1YB
Help and Independent Advice
Citizens Advice Bureau Citizens Advice Bureau
8 Buccleuch Street 14a John Street
Dalkeith Penicuik
Midlothian Midlothian
EH22 1HA EH26 8AB
General Enquiries: 0131 660 1636 General Enquiries: 01968 675259
Money Advice Line: 0131 654 4369 Money Advice Line: 01968 679918
THE SCOTTISH WELFARE FUND – APPLICATION FORM 5
APPLICATION QUESTIONS
Part 1. General information about you and your family.
Please give us some information about you, your partner if you have one, and the
other people who live in your house with you.
You Your partner
Title
Surname
Othersurnamesyouhaveused
Allothernames
Yourcurrentaddress
Ifyouhavebeenatthisaddress
forlessthan3months,please
giveyourpreviousaddress
NationalInsurancenumber
Dateofbirth
Sex
Male
Female
Male
Female
Adaytimephonenumberso
thatwecancontactyouifwe
needmoreinformation
Maincontactnumber Maincontactnumber
Othercontactnumber Othercontactnumber
Emailaddress
Whatisthebestwaytocontactyou?
6 THE SCOTTISH WELFARE FUND – APPLICATION FORM
About your home.
Whatsortofplacedoyoulivein?Pleasetickonefromthislist:
RentfromtheCouncil
Rentfromaprivatelandlord
Rentfromahousingassociation
Ahostel
Bedandbreakfast
Caravanormobilehome
Aresidential/carehome
Aresidentialschoolorchildren’saccommodation
Supportedaccommodation,forexample
shelteredhousingorhousingwithsupportafter
being homeless
Livingwithfriends/relatives
Livingwithownparents
Ownyourhomeorjointlyownyourhome,
includingwithamortgage
ArmedForcesaccommodation
Ahospital
Prisonoryoungoffender’sinstitution
Other
Ifother,pleasegivedetails:
Howlonghaveyoulivedhere?
Ifyourhomeisrented,pleasetellusaboutthelandlord.
Landlord’sname:
Landlord’sphonenumber:
Ifyouareinaprisonoryoungoffender’s
institution,pleasegiveyourprisonernumber:
Whatisthenameoftheinstitutionyouarein?
THE SCOTTISH WELFARE FUND – APPLICATION FORM 7
About other people who live with you.
Pleasetellusaboutallthepeoplewholivewithyou,includingchildrenthatyou
support.Achildis16orunderoraged17-19andstillinfull-timeeducationor
includedontheirparent’sbenetclaim.Thisincludesbabieswhohavenotyetbeen
bornso,ifsomeoneispregnant,pleaseincludedetailsofthebaby.
Name/s Dateof
birth/due
date
Relationshiptoyou Pleasetickthis
boxifyou
receiveChild
Benetforthis
person
Pleasecontinueontheblankpageatthebeginningofthisformifyouneedmore
space.
PleasetellusaboutanyapplicationsyouhavemadeforCrisisorCommunityCare
Grantsinthelast12months,includingwhenyouwerelivinginanotherCouncilarea.
Wasagrantgiven?Yes
No
Haveyourcircumstanceschangedsincethelastapplication?Yes
No
Ifyes,pleasetellushow:
8 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Part 2. About money you have and receive.
In order to get a Crisis Grant or Community Care Grant, you need to be on certain
benefits. Are you or your partner receiving any of the following welfare benefits?
Please tick all of the benefits you and your partner are getting or will be getting:
You Your partner
IncomeSupport
PensionCredit
HousingBenet
CouncilTaxReduction
Jobseeker’sAllowance(contribution-based)
Jobseeker’sAllowance(incomebased)
EmploymentandSupportAllowance
(contribution-based)
EmploymentandSupportAllowance(income
related)
IncapacityBenet
DisabilityLivingAllowance
PersonalIndependencePayment
WorkingTaxCredit
ChildTaxCredit
ChildBenet
UniversalCredit
CarersAllowance
PensionCreditPlus
AreyouoryourpartnerwaitingtohearfromDWP
aboutaclaimorappealforanywelfarebenets?
Yes
No Yes
No
Pleasetellusaboutthis,forexamplewhatyouappliedforandwhenandwhois
dealingwithyourapplication:
THE SCOTTISH WELFARE FUND – APPLICATION FORM 9
About money you or your partner get regularly.
Tell us about your regular income, for example from Income Support, Jobseeker’s Allowance, Employment and Support
Allowance, Pension Credit, Child Benefit, Housing Benefit, Disability Living Allowance, interest on savings, pensions and child
maintenance.
Typeofmoney Howmuchare
yougetting?
Howoften? Whenwasthe
lastpayment?
Whenwillthe
nextpayment
be?
Whomakesthe
payment?
Isthismoney
yours,your
partnersor
heldjointly?
For example: Child
Benefit
£81.20 Every
4 weeks
8/10/12 5/11/12 HMRC Mine
10 THE SCOTTISH WELFARE FUND – APPLICATION FORM
About money you or your partner get regularly (continued).
Haveyouoryourpartnerreceivedanymoneyrecentlyapartfromyourregular
income?Forexamplenalwages,holidaypayorredundancypay?Yes
No
You Your partner
Whatmoneydidyouoryour
partnerreceive?Pleasegive
details:
Wheredidthemoneycome
from?
Howmuchdidyouoryour
partnerget?
Whendidyouoryourpartner
getit?
Isthereanymoredue?
Yes
No Yes
No
Howmuchandwhen?
AreyousubjecttoanysanctionordisallowancerelatingtoDWPbenets?
Thismeansthatyourbenethasbeenreducedorstoppedeventhough
youarestillentitledtoit,becauseofsomethingyouhavedone.
Yes
No
Ifso,pleasetellusaboutthis.Forexample,thereasonforthesanction,whenit
startedandwhenitwillnish.WewillnotgiveaCrisisGrantforlivingexpenses
ifyouaresubjecttoaDWPsanctionunlessyouareapplyingforfoodforchildren.
WemaybeabletogiveyouaCrisisGrantifyouhaveexperiencedadisaster.
THE SCOTTISH WELFARE FUND – APPLICATION FORM 11
About savings and other money you could use. Please tell us about any money,
savings, assets or capital that you have. This includes cash, money in a bank, building
society or credit union. It might also be National Savings, Premium Bonds, stocks and
shares, trust funds or endowment policies. We will not give you a grant if we think
you have money that you could use, but some types of money can be ignored when
we look at your application, for example business assets, rights in pension schemes,
funeral plans and compensation for late payments of benefits.
You Your partner
Doyouoryourpartnerhaveanyother
moneyorsavingslistedabove?
Yes
No Yes
No
Ifso,howmuch?
Pleasesaywherethemoneyisheld,for
exampleinabankaccountorbuildingsociety
orcreditunion.
Canyougettothismoneytouseit?
Yes
No Yes
No
IfNo,whynot?
Isthereanyothermoneyyouoryourpartner
coulduse,e.g.acreditcard,authorised
overdraft?
Yes
No Yes
No
Pleasetellusaboutthis:
Doyouoryourpartnerownahouseor
propertyapartfromwhereyoulive?
Yes
No Yes
No
Pleasetellusaboutthis:
Canyouoryourpartnergethelpfrom
anywhereelse,incashorinkind,forexample
fromfriendsandrelatives,charitiesor
benevolentfunds(thismightinclude
borrowingitems)?
Yes
No Yes
No
Whathaveyouoryourpartnertried?
12 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Part 3. What type of grant you are applying for and why. Please fill in the section
which best fits your situation.
AreyouapplyingforaCrisisGrantbecause
ofadisaster?Adisasterisasudden
misfortunewhichusuallycausesdamageor
destructiontopropertyand/orpossessions,
forexampleaoodorare
Yes
No
IfYes,pleasellinSection3ato
applyforaCrisisGrantinaDisaster
AreyouapplyingforaCrisisGrantbecause
ofanemergency?Anemergencyisa
sudden,urgent,unexpectedeventwhich
usuallyneedsimmediateaction,for
exampleifyouhavelostallofyourmoney
Yes
No
IfYes,pleasellinSection3bto
applyforaCrisisGrantinan
Emergency
AreyouapplyingforaCommunityCare
Granttohelpyouliveinthecommunity
ratherthangoingintocareorstayingin
care?
Yes
No
IfYes,fromthelistbelow,tickthe
reasonwhyyouareapplyingandplease
llinSection3ctoapplyfora
CommunityCareGrant.
• Youneedhelpsettinguphomeinthecommunityafterbeingincare
• Youneedhelptostayinthecommunityratherthangoingintocare
• Youneedhelptosetuphomeinthecommunityaspartofaplanned
re-settlementprogrammewithanorganisationhelpingyou
• Youneedhelptoprovideasafeandsecureenvironmentforyourchild/
childrenbecauseofexceptionalpressureonyourfamily,forexample
becausethefamilyhasbrokendown
• Youneedhelptocareforaprisoneroryoungoffenderonreleaseor
temporarylicence
3a. Crisis Grant in a Disaster. Please fill in this section if you have suffered from a
disaster which may cause serious damage or risk to your or your family’s health or
safety. You can apply for living expenses and for essential items for your home
which you need as a result of the disaster.
Pleasetickthesortofdisasterthathas
affectedyou:
fire
majorood
gasorotherexplosion
anothertypeofdisaster
Ifitisanothertypeofdisaster,pleasesaywhatitis:
Whathappened?
THE SCOTTISH WELFARE FUND – APPLICATION FORM 13
Whendidithappen?
Didanyemergencyservicesattend?
Yes
No
Whatwasdamaged?
Doyouhavehouseholdinsurance?
Yes
No
IfYes,areyouplanningto,orhaveyou,madeaclaim?
Yes
No
Whatmoneydidtheinsurancecompanygiveyouandhowmuchisleft?
Howhasthedisasteraffectedyouandyourfamily?
Ifmoneyhasbeenspent,saywhaton:
WecanonlymakeaCrisisGrantforlivingexpensesifthereisaseriousriskor
dangertoyouroryourfamily’shealthandsafety.Pleasetelluswhatthisrisk
ordangeris:
14 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Please tell us about the things that you are applying for, how many you need; this
may include costs for daily living, such as food or electricity. As you are applying
because of a disaster, you can also apply for household items which have been
damaged, for example a cooker.
Whatdoyouneed? Howmanyorhow
muchdoyouneed?
Howmuchdoyou
thinkitwillcost?
Whowilluseit?
For example:
A cooker
1 £x plus £x delivery
and £x installation
Me and my partner
to cook for the
family
3b. Crisis Grant in an Emergency. Please fill in this section if you are applying for a
Crisis Grant because of an emergency which may cause serious damage or risk to
you or your family’s health or safety. If you are applying because of an emergency,
you can only apply for living expenses such as food or travel, not for items for your
home.
Pleasesaywhattheemergencyis:
Whathappened:
Ifmoneyhasbeenlost,pleasesayhowmuchismissing £
Ifmoneyhasbeenstolen,pleasesayhowmuchismissing £
Haveyoureportedthelosstothepolice?
Yes
No
Pleasegivetheincidentnumber:
THE SCOTTISH WELFARE FUND – APPLICATION FORM 15
Pleasesayhowmuchfoodyouhaveleftandhowlongthiswilllast:
Doyoupayforyourgasorelectricitywithapre-paymentmeter?
Yes
No
Howmuchcreditisleftonthemeter? £
Howlongwillitlast?
WecanonlymakeaCrisisGrantforlivingexpensesifthereisaseriousrisktoyou
oryourfamily’shealthandsafety.Pleasetelluswhatthisriskis:
Please tell us about the living costs that you are applying for and how much you
need. This may include items such as electricity or travel expenses. If you need
food, please say how many days you need it for. You cannot apply for household
items if you are applying for a grant because of an emergency. Please use a new line
for each new thing.
Whatdoyouneed? Howmanyorhow
muchdoyouneed?
Howmuchdoyou
thinkitwillcost?
Whowilluseit?
For example: food
until next benefit
payment
x days £x Me, my partner
and two children
PleasegotoSection4withotherinformation,unlessyouarealsoapplyingfora
CommunityCareGrant.
16 THE SCOTTISH WELFARE FUND – APPLICATION FORM
3c. Community Care Grant – to help you live in the community rather than being in
care. This includes:
• settingupinthecommunityafteraperiodincare
• wantingtostayinthecommunityratherthanhavingtogointocare
• takingpartinaplannedre-settlementprogrammeafteranunsettledwayoflife
• afamilyfacingexceptionalpressure,forexamplebecauseoffamilybreakdown,
andneedhelptoprovideasafeandsecureenvironmentforchildren
• caringforaprisoneroryoungoffenderonreleaseontemporarylicence.
Areyouplanningtomove?Ifnot,goto
–Yourcircumstances
Yes
No
IfYes,pleasetellustheaddressyouare
movingto:
Ifyouaremoving,pleasetickthesortof
homeyouareplanningtomoveto:
Ahomeyouown
Rented–
unfurnished
Rented–partly
furnished
Rented–fully
furnished
Other
Ifyouhavetickedother,pleasetellusaboutthis:
Ifthepropertyisrentedpleasetellusaboutthelandlord:
Landlord’sname:
Landlord’sphonenumber:
THE SCOTTISH WELFARE FUND – APPLICATION FORM 17
Your circumstances
Pleasetelluswhyyouneedhelptosetuporstayinthecommunity:
Areyoufollowingaprogrammeofsupporttohelpyoure-settleinthecommunity
afteranunsettledwayoflife?Yes
No
Whyareyoufollowingtheprogramme,forexampleisitbecauseyouhavehad
problemswithaddictions,orareyoufollowingaprogrammeofsupport,for
example,becauseyouhavebeenincareorbeenhomeless?
Whatdoestheprogrammeofsupportinvolve?
Please fill in this section if you need help to provide a safe and secure environment
for your child or children because you are facing exceptional pressure and do not
have the resources to meet these costs.
Whatistheexceptionalpressurethatyouoryourfamilyareunder?
18 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Whatistheimpactonyourchild/children?
Please fill in this section if you need help caring for a prisoner or young offender on
release on temporary licence.
Name:
Dateofbirth:
Theirrelationshiptoyou:
Nameofinstitution:
Theirprisonernumber:
Whatdatedoestheleavestart?
Whatdatedoestheleavenish?
Tell us about the things that you are applying for. This may include items such as a
bed, bedding, clothes or items for the kitchen such as a cooker. It may also include
services such as removals or travel costs. If you are given a grant, you may be asked
to provide receipts to show that you have bought the items the grant was awarded
for. Please make sure you keep receipts.
Pleasetellusasmuchasyoucanabouthowthesethingswillhelpyou.
• Ifyouneedtoreplacesomething,telluswhatiswrongwiththeoneyouhaveand
whyyouneedtoreplaceit.
• Ifyouneedsomethingforthersttime,telluswhyyouneedit.Pleasetellus
exactlywhatyouneed,forexample,ifyouneedclothing,whattypeofclothing
youneed.
• Forthingslikecurtainsandcarpets,tellusthesizesofthewindoworroomthey
arefor.
• Ifyouneedsomethingwithspecialfeaturesoradaptations,telluswhatthese
featuresareandwhyyouneedthem.Ifyouneedmorespacetotellusaboutwhat
youneed,pleasecontinueontheblankpageatthebeginningofthisform.
THE SCOTTISH WELFARE FUND – APPLICATION FORM 19
Whatdoyouneed? Howmanyorhow
muchdoyouneed?
Howmuchdoyou
thinkitwillcost?
Whowilluseit?
For example: A
new winter jacket
because I have put
on weight while I
was in care and the
old one doesn’t fit
any more
1 £x Me
Please tell us about any organisation that is helping you either to set up in the
community or to stay in the community.
Pleasegivethenameoftheorganisation
helpingyou:
Pleasegivethenameoftheperson
helpingyou:
Pleasegivethephonenumberofthe
personhelpingyou:
Howaretheyhelpingyou?
20 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Part 4. Other information that will help us to make a decision.
When we decide whether or not to give a grant, we look at how much difference a
grant will make to the person applying or the person they care for. This means that
we need to know about any problems, difficulties or special circumstances for you or
the people you live with. We also need to know about changes in your circumstances.
Please answer the questions below, telling us about things that are affecting you,
how they have affected you and what help or treatment you have had. Please also
tell us if you have had to spend extra money because of these problems.
Whatwillhappenifyoudonotgetagrant?
Pleasetellusifyouorsomeonenamedintheapplicationhashealthproblemssuch
aschronicorterminalillness,disabilityforexampledeafnessorblindnessorany
medicalcondition:
Pleasetellusifyouorsomeonenamedintheapplicationhasmentalhealth
problems:
THE SCOTTISH WELFARE FUND – APPLICATION FORM 21
Isthereanyreasonwhyyouwouldneedaspecialtypeoftheitemthatyouhave
askedfor,forexampledoyouneedanadaptationtothethingsyouhaveaskedfor
becauseofadisability? Yes
No
Pleasetellusaboutthis:
Pleasetellusifyouorsomeonenamedintheapplicationhaslearningdifcultiesor
physicalimpairments:
Pleasetellusifyouorsomeonenamedintheapplicationhasproblemswith
addictionsorsubstancemisuse:
Pleasetellusifyouorsomeonenamedintheapplicationhasproblemsbecauseof
age,forexampledifcultyingettingaroundorneedinghelplookingafter
themselves:
22 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Pleasetellusifyouorsomeonenamedintheapplicationhasbeenrecently
homelessandhowthishappened.Pleasegivethedates:
Pleasetellusifyouorsomeonenamedintheapplicationhashadasignicant
changesincircumstances,forexampleredundancy,evictionorrepossessionor
leavingtheArmedForces:
Other Information –Pleaseusethisspacetotellusaboutanythingelseyouthink
weneedtoknowaboutthatyouhavenotalreadymentionedintheform.These
maybethingslikefamilyproblems,poorlivingconditionsorcopingafteradisaster.
Tellusaboutanythingthatmakesyoursituationunusuallyhardtocopewithandwhy:
THE SCOTTISH WELFARE FUND – APPLICATION FORM 23
Part 5. About other support you receive or might want to receive.
Wemayknowaboutotherservicesthatyouwouldnduseful.Pleaseletusknow
aboutservicesthatyouarealreadyusing.
Didsomeonehelpyoutollinthisform,forexampleafriendor
familymemberoranadviceworker?
Yes
No
Areyouoryourpartnerincontactwithotherservices,for
examplesocialwork,housing,welfarerights,healthcareor
others?
Yes
No
Pleasetelluswhyyouareintouchwiththisserviceorservices:
Organisation/Department Nameofperson Phonenumber
Wouldyoulikeanadviceworkertocheckthatyouaregettingall
ofthebenetsthatyouareentitledto?
Yes
No
Doyounditdifculttopayyourdebts?Wouldyoube
interestedinspeakingtoadebtadviser?
Yes
No
Doyouthinkyouwouldndsomeadviceonmoneymanagement
helpful?
Yes
No
IfyouhaveansweredYestothequestionsabove,wemaygive
yourdetailstosomeonewhocoulddothisforyou,dependingon
howmanypeopleareinterestedintheseservices.Thismaybe
someonefromtheCouncilorfromavoluntaryorganisation.
Wouldyoubehappytobecontactedabouttheseservices?
Yes
No
24 THE SCOTTISH WELFARE FUND – APPLICATION FORM
Part 6. Declaration and what happens next.
Ifwedecidetomakeagrant,wemaypayyouagrantorgiveyouvouchersorthe
itemsyouneed.Ifwearegoingtogiveyouitemsorvouchers,wewillcontactyou
toarrangefordeliveryorcollection.
About the account you want to use
Ifwearegoingtopaycash,wemayneedtoknowyourbankaccountdetails.Itis
veryimportantyoucompleteALLboxescorrectlyincludingthebuildingsocietyroll
orreferencenumberifyouhaveone.
Ifyoutellusthewrongaccountdetailsyourpaymentmaybedelayedoryoumay
losemoney.Youcanndtheaccountdetailsonyourbankdebitcardorbank
statements.Ifyouarenotsureaboutthedetails,askthebank,buildingsocietyor
otheraccountprovider.Youcanuseanaccountinyournameorajointaccount.
Ifyoudonothaveanaccount,andarenotplanningtoopenone,pleasetickthebox
andwewillcontactyoutodiscussthebestwaytomakeapayment.
Ifyouareanappointeeoralegalrepresentativeactingonbehalfoftheapplicant,
theaccountshouldbeinyournameonly.Tobepaidintoacreditunionaccountyou
mustprovidethecreditunionaccountdetails.Yourcreditunionwillbeabletohelp
youwiththis.
Account details
Nameofaccountholder:
Fullnameofbank,buildingsocietyorotheraccountprovider:
Sortcode
Accountnumber
Buildingsocietyrollorreferencenumber
Ifyoudonothaveanaccountanddon’tintendtoopenonetickhere
Declaration
Please read the declaration carefully and make sure you understand it before signing and
dating the form. We cannot make a decision about your application unless you have signed
the form. Even if someone has filled in the form for you, you must sign it if you can. Make
sure that you understand what they have written before you sign the declaration. It is an
offence to give false information.
Tick one of the following:
This is my application for a Crisis Grant
Community Care Grant
• I have read and understood the guidance notes that come with this form.
• I understand that Midlothian Council:
o will use the information I have given to decide whether to award me a
grant;
o will check the information I have given with the organisations I have
named on the form and make any other enquiries to check that the
information I have given is correct;
o will use the information and share it with other agencies, including
the Scottish Government, for research and analysis to monitor this
service and provide better services;
o will keep a copy of this application in accordance with its retention
policy.
o may decide to make a grant for supervised spend by the Council or by
another organisation;
o may require me to provide receipts for the things I buy, so that I
must keep my receipts.
• I declare that, if I am awarded a grant, I will spend it on the things I have
asked for.
• I also declare that the information I have given on this form is correct and
complete as far as I know and believe.
•
Signature:
Date:
Print your name:
If this form has been filled in by someone different from the person claiming. If you are
signing this form for someone else who cannot apply for themselves, please complete this
section. You do not need to complete this section if you have helped someone fill in the form
but they are signing it.
Please print the name of the person who completed the form:
Contact address:
Telephone number:
THE SCOTTISH WELFARE FUND – APPLICATION FORM
Email address:
What is your relationship to
the applicant?
Please give the reason why the applicant was unable to complete the form:
Please ask the applicant to sign this section to give you the authority to apply on their
behalf.
I hereby authorise the person named above to apply for a Crisis Grant or
Community Care Grant on my behalf. I would like them to receive all
correspondence about the claim.
Signed
You should complete the rest of the form with the details of the person you are filling in
the application for. We will send all correspondence to you.
What to do now
• Check you have answered all the questions and given all information requested
• Initial any alterations
• Check you have signed the form
• Send or take your form to the Council you are applying to. You can find Council contact
details on the Scottish Government’s Scottish Welfare Fund website
Processing times
If your application is for a Crisis Grant, we will process it as soon as possible. We aim for
all applications to be processed in 2 working days. We aim to process Community Care
Grant applications within 15 working days.
You will receive a letter to tell you whether or not you will receive a grant. If your
application is urgent, we will also contact you by phone to let you know.
What to do if you disagree with our decision: If you are not happy with the decision on
your application you can ask us to look at it again. The Crisis Grant and Community Care
Grant section at the Council will look at your application again to check whether they have
made the right decision. You must write to us within 20 working days of the decision and tell
us why you want a review.
THE SCOTTISH WELFARE FUND – APPLICATION FORM
Helping us to improve our service
The Scottish Welfare Fund is a new fund. We want to understand how well it is working so
that we can improve it in the future. We would like you to answer these questions to help us
but they are not part of your application so you do not have to. If you do answer them, we will
not use the answers to any of these questions to decide whether or not to give you a grant.
Would you be willing to answer some questions about your
No
experience of using the fund? If you answer Yes, we may
pass on your contact details to approved researchers to
contact you direct to ask you some questions.
We want to understand who is applying to the Scottish Welfare Fund so that we can make
sure that particular groups are not disadvantaged. It would be helpful if you could tick the
boxes below that most closely fit you:
What religion, religious denomination or body do you belong to?
None
Buddhist
Other Christian
Pagan
Church of Scotland
Sikh
Hindu
Roman Catholic
Jewish
Muslim
Another religion, please write in
What is your ethnic group?
Chinese, Chinese Scottish
White Scottish
or Chinese British
Other British
Other Asian, Asian Scottish
Irish
or Asian British
Gypsy/Traveller
African, African Scottish
or African British
Polish
Other African
Other white ethnic group
Mixed or multiple ethnic group
Caribbean, Caribbean Scottish
or Caribbean British
Pakistani, Pakistani Scottish or
Pakistani British
Black, Black Scottish
or Black British
Indian, Indian Scottish or
Indian British
Other Caribbean or Black
Bangladeshi, Bangladeshi Scottish
Arab, Arab Scottish
or Bangladeshi British
or Arab British
Other ethnic group, please write in
THE SCOTTISH WELFARE FUND – APPLICATION FORM
Do you have a physical or mental health
Yes
No
condition or illness lasting or expected to
last 12 months or more?
Does this condition or illness affect you in any of the following areas? Please
tick all that apply
Vision (for example blindness or partial sight) Hearing
(for example deafness or partial hearing)
Mobility (for example walking short distances or climbing stairs)
Dexterity (for example lifting or carrying objects, using a computer keyboard) Learning
or understanding or concentrating
Memory
Mental health
Stamina or breathing or fatigue
Socially or behaviourally (for example associated with autism,
attention deficit disorder or Aspergers’ syndrome)
Other, please write in
THE SCOTTISH WELFARE FUND – APPLICATION FORM
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