Michael Lowe's and Associated Charities, Lichfield
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APPLICATION FOR FUEL GRANT

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Paper copies of the Application forms are also available - please contact us for more information.

PLEASE ANSWER ALL QUESTIONS
Name(Required)
DD slash MM slash YYYY
Address(Required)
Marital Status
Are you?
DEPENDANTS WHO LIVE WITH YOU (spouse or partner) (State name(s) and date(s) of birth
Please click on the + button to add new entries
Name
Date of Birth
 
NON-DEPENDANTS WHO LIVE WITH YOU (spouse or partner) State name(s) and date(s) of birth
Please click on the + button to add new entries
Name
Date of Birth
 
Do you have a bank /building society account?
Please tick if you ARE in receipt of any of the following?
Please tick
Please tick If you are NOT in receipt of any of the above

PLEASE ANSWER BELOW ONLY IF YOU ARE NOT in receipt of Pension Credit, Housing Benefit, Council Tax Benefit, Disability Living Allowance or Attendance Allowance

WEEKLY INCOME

Please give details

PLEASE ANSWER BELOW ONLY IF YOU ARE NOT in receipt of Pension Credit, Housing Benefit, Council Tax Benefit, Disability Living Allowance or Attendance Allowance

WEEKLY OUTGOINGS

Consent

Consent(Required)
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS APPLICATION FORM IS COMPLETE AND CORRECT. I UNDERSTAND THAT THE TRUSTEES MAY WISH TO VERIFY THE REPLIES GIVEN AND I AUTHORISE AND PERMIT THE TRUSTEES TO RELEASE SUCH INFORMATION CONTAINED IN THIS FORM AS MAY BE REASONABLY NECESSARY TO ENABLE SUCH VERIFICATION

I CONFIRM THAT I WILL USE ANY GRANT MADE TO ME TOWARDS MY FUEL BILLS
DD slash MM slash YYYY
NOTE: Persons qualified to be considered for a Grant must be needy honest industrious householders of 70 years and over living in the CITY OF LICHFIELD and not residing permanently in any State or Local Authority establishment. All information supplied is confidential to the Trustees and their employees and will not be divulged to any other person except in the circumstances outlined in (d). If the Trustees subsequently discover that any information given is incorrect they reserve the right:

(a) to withdraw the offer of a grant
(b) require the repayment of any grant made
(c) to refuse to consider any future applications
(d) where it appears that a fraudulent application may have been made to report the matter to the appropriate authorities and/or institute any other proceedings which they consider appropriate
(e) any information provided will be treated as confidential and your application will be destroyed within 12 months

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