Grant Application Form

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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.

Please tick to confirm

I CONFIRM THE ABOVE

Part 1 - Applicant Name and Details

Title

First Name

Last Name

Contact Telephone

Do you know the applicants email address?

YesNo

Client/ Applicants email (do NOT enter your email/Referrers email here)

Status

Date of Birth (DD/MM/YYYY)

Occupation/former occupation

Applicant Address

Start Typing address in this field and select the correct address

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

Address Line 1

Address Line 2

Town/City

County

Country

Post Code

Part 2 - Referrer Name and Contact Details

Title

First Name

Last Name

Contact Telephone

Job Title

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

REFERRAL AGENCY LOOKUP

Related Address (read only)

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

Corrected details (optional)

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

Organisation Type

Type other

Referring Agency or Organisation name

Referral Agency Address

Start Typing address in this field and select the correct address

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

Address Line 1

Address Line 2

Town/City

County

Country

Post Code

AccountID(hidden)

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.

What is the applicant's medical diagnosis?

Primary medical condition relevant to this application

Alzheimers disease and other dementiasASD/C, Autistic spectrum disorder, ADHD, Asperger’s syndromeCancerCardio-vascular diseaseChronic Kidney DiseaseChronic Obstructive Pulmonary Disease (COPD)Cystic FibrosisDiabetes mellitusHypermobility syndromes, Ehlers-Danlos SyndromeInflammatory bowel diseases, Crohn’s disease, ColitisLearning difficultiesMental illness, Mental health conditionsMultiple conditions of ageingMusculo-skeletal diseasesNeurological diseases and conditionsNeuro-muscular diseasesSensory impairment – visualSensory impairment – hearingSensory impairment (visual, hearing)Spinal injuries and degenerative diseasesOther

Other primary medical condition

Secondary medical conditions (tick all that apply)

Other secondary medical condition

How does the applicant’s medical condition affect their ability to lead an independent life?

What does the applicant need and how will it support better health outcomes?

What is the main benefit for the applicant from an IAH grant?

What other key benefit would the applicant get from an IAH grant?

Please upload a recent letter or report from a qualified health or social care professional confirming the case of need and supporting this application

Part 4 - Household Details

Does the applicant live alone?

YesNo

Type of Accommodation

Other Member of Household

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

First Name

Last Name

Age

Relationship to Applicant

Employment

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).

Total weekly Income £

enter actual amount

Total annual Income £

this auto-populates with weekly income entered above x 52

Please tick all sources of income that the applicant receives

Income SupportIncapacity BenefitJobseekers AllowanceEmployment and Support Allowance (ESA)Child BenefitChild Tax CreditHousing BenefitWorking Family Tax CreditDisability Living Allowance-CareDisability Living Allowance-MobilityPersonal Independence PaymentAttendance AllowanceCarer’s AllowanceEarningsPensionsUniversal CreditOther

Total household savings £

Total household debts £

including mortgage

Part 6 - Other Funding and Previous Grants

Have you applied to any other charities/organisations for assistance with this item or raised any funds through fundraising events?

YesNo

Funding from another charity or organisation

Name of charity/ organisation

Details

Total requested £

Total secured/pledged £

Is there any statutory financial assistance for this item?

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

Please provide details of statutory financial assistance

What personal contribution can the applicant make towards the cost of the item (£)?

Has the applicant received help from Independence at Home before?

YesNo

Provide details of previous help from Independence at Home

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.

State the item of equipment or building work for which grant required

Grant category

Total Cost of Item of Equipment or Works £

Total Amount of Grant Requested from Independence at Home £

Please upload a quotation on the proposed supplier/contractor’s letterhead paper. This quotation must have been sourced and agreed with the applicant.

Payee Details for the Grant

PLEASE NOTE

INDEPENDENCE AT HOME AWARDS GRANTS BY BACS TRANSFER.

WE DO NOT MAKE PAYMENTS TO INDIVIDUAL APPLICANTS.

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.

Payment to Referrer or Supplier

ReferrerSupplier

Supplier Name

Supplier Email

Name on Account

Account number

enter 8 digit account number

Sort Code

enter 6 numbers without spaces or dashes e.g. 347658

Payment Ref

max 8 characters

Name of Bank

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

TICK BELOW TO CONFIRM

I agree to Independence at Home storing this data and contacting me regarding this application

How Heard

How did you hear about Independence at Home?

Other 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.

Ethnicity

What is the applicant’s ethnic group?

Other ethnic group

Gender

What is the applicant's gender?

other gender (optional)

Is the gender the applicant identities with the same as their gender registered at birth?

Sexual Orientation

Which of the following best describes the applicant's sexual orientation?

Other 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:

MAKE A CORRECTION
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.

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