Grant Application Form

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Please complete the following form and submit.
Referrer Declaration

I am completing this form on behalf of my client who is deemed to be the applicant. The personal information I am providing about the applicant is accurate to my knowledge.

I have explained to the applicant that, in making this referral, I am sharing their personal data, including health information, and they have agreed to this.  I have explained that Independence at Home will be using the information to assess their grant application.

I confirm that I have explained the application process and have the permission of the applicant to share all the information included within this grant application. (Please note that we are unable to consider grant applications where you do not have permission to share such information.)

If the application is successful, I agree to receive a short monitoring questionnaire and to complete this in relation to the grant that has been awarded by Independence at Home.  

Part 1 - Applicant Name and Details

Applicant Address

matched addresses will start to appear in a drop down list, click on the correct address and the fields below will auto-populate

Part 2 - Referrer Name and Contact Details

Referring Agency or Organisation
Search for your referral agency in the REFERRAL AGENCY LOOKUP field below. If a referral agency has made a previous referral to Independence at Home in the last few years they should be listed (over 900 are listed).

Search by a part of your organisation name, e.g. enter 'Citizens Advice' and a list of different Citizens Advice organisations will be listed (then select the specific agency). When you select a referral agency the read only 'Related Address' field will auto-populate.

If your referral agency is NOT listed select the option 'a. AGENCY NOT FOUND' and an additional section will appear to complete the details.

If your referral agency IS listed but the name is slightly different or address is different complete the optional 'Corrected details' field

Will auto-populate if you select a referral agency in the search field above

Referring Agency details other (if not listed in REFERRAL AGENCY LOOKUP above)

Referral Agency Address

matched addresses will start to appear in a drop down list, click on the correct address and the fields below will auto-populate

Part 3 - Case of Need and Medical Confirmation
Please ensure that you explain clearly the link between the applicant’s medical needs and the equipment or building works for which grant support is being requested.
Applications based largely on financial hardship and without sufficient evidence of need due to disability or long-term illness, will not pass our assessment process. 

Part 4 - Household Details

Other Member of Household
Please give names and ages of all members of the household and details of their employment where applicable

Part 5 - Household Income
Please note: -
If the applicant is married or living with partner and sharing household costs, please identify the total and sources of weekly income for both parties.
If applicant is over 18 years and still living with parents, please identify the total and sources of weekly income for that individual only.
If the applicant is under 18 years, please identify the total and sources of weekly income for the parent(s).
enter actual amount
this auto-populates with weekly income entered above x 52

including mortgage
Part 6 - Other Funding and Previous Grants

Funding from another charity or organisation

e.g. a DFG or a voucher from NHS Wheelchair Services

date, amount, item funded etc.
Part 7 - Purpose of Grant and Amount Requested 
Please note that Independence at Home grants are modest and range between £300 - £600 depending on the item of equipment or building work needed.

Payee Details for the Grant



Grant Payments can only be made to:

The bank account of the referring organisation;
The bank account of the company supplying the goods or services.

Referrers must liaise with the applicant and the supplier once they have received notification that a grant award has been paid. This includes ensuring that the order has been placed and that arrangements are in place for delivery of equipment or start of building works.

enter 8 digit account number
enter 6 numbers without spaces or dashes e.g. 347658
max 8 characters
Part 8 - Data Protection and Additional Information
The confidentiality of your personal information is of paramount importance to us.  We are registered with the Information Controller’s Office as a Data Controller under the Data Protection Act 1998 and will process and hold your information in accordance with legislation.

IAH Charity Company Limited trading as Independence at Home, registered in England and Wales.  Company Number 7620400 Registered Charity Number 1141758. Registered Office - Congress House, 14 Lyon Road, Harrow, HA1 2EN

How Heard

Please complete the following 3 questions to help us to understand who we are reaching and to ensure that we serve everyone in our community. The information below is confidential and will only be used to provide an anonymised annual summary of the ethnic composition, gender and sexual orientation of the beneficiaries of our grants to demonstrate that our grants are available to all.


Sexual Orientation

After you click the REVIEW COMPLETED FORM button below, please review your completed application form carefully.


At the end of the final page, you can:

  • PRINT A COPY of your application form
  • SAVE a copy of the form to a file on your computer/laptop in the normal way
  • CONFIRM that you wish to submit your application


Don’t forget, on the next screen, when you are ready to submit your application form, just click the CONFIRM button.