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Application for Assistance Form

In Confidence

  1. Guidance notes for completing the form
    1. Personal Details
      The ‘applicant’ may be a person who has served in our industry, or their spouse/ partner/widow/widower/other family member
    2. About You and Your Family/Dependants
      There are numerous occupational charities that can be approached for additional grants and it is important to provide details of the nature and type of employment of all relevant parties (applicant/spouse/partner/family/dependant).
      Details are required of children/dependants, irrespective of their age, because of the financial impact they might have on the household if they are still living at home.
    3. Savings
      Savings can affect both entitlement to benefits and the way in which other charities view applications. All savings are taken into account when assessing need
    4. Debts
      Details of all outstanding debts must be included. If you have already sought advice, this should be included in the ‘other debt information’ box
    5. Family/Dependant Health Issues
      Refer to the details you have completed in Section 5 and highlight any illness or disability for any of those listed
    6. HM Armed Forces
      It is important that information regarding armed forces and related associations is included. This will provide helpful information if the need arises to approach other charities, specifically those dealing with the armed forces.
    7. Other Organisations Approached
      It is very important to complete this if you have or are receiving assistance from other charities or organisations, so that we do not approach them twice
    8. General Information
      Supply as much information about needs as possible. For costly items such as house repairs and electrically powered vehicles, we may need to approach other charities who will expect us to have established all known information. For most disability equipment we will be requesting medical evidence to support your request.
    9. Declaration
      It is a requirement of the GDPR that you understand why this declaration is necessary.
      The purpose of the declaration is to ensure you are satisfied that the information provided is correct and that you authorise the Electrical Industries Charity to approach other charities. If personal details of your spouse/partner are included, their consent should be obtained wherever possible before the form is returned to the charity.
    10. GDPR
      Please read this carefully before signing. It defines your rights as an individual in relation to the information held about you and how it may be used.
      In addition you are entitled, under the GDPR, to see the completed Application Form and related reports.
    11. Submit your supporting information with Lightning
      We’ve introduced a new way for you to verify your financial situation by quickly and securely connecting your bank accounts, and uploading your supporting documents, through our trusted partner, Lightning.

      Connecting your accounts replaces the need for you to upload bank statements with a safer and easier digital process. It may also help us to review your situation more quickly and give you a decision sooner.

      You will also need to upload the following supporting documents, as are relevant, on Lightning:
      • Letter(s) from the DWP regarding benefits/pensions/tax credits
      • 3 months occupational or private pension payslips
      • 3 months payslips
      • (For accounts that are not online) full bank statements for 3 months for all accounts
      • If application is for mobility or disability equipment or adaptations then it is likely that an Occupational Therapist report will be required and this can be discussed on receipt of the application.


      After you have submitted this application, you will receive an email from Lightning with a secure link to guide you through the quick and safe connection and upload process. Emails will be sent by the end of the next working day. Please remember to check your spam and junk folders.
    12. Assistance with this form
      Should you require any assistance in completing this form, please call the number on the accompanying letter or our Access Assistance Helpline on 0800 652 1618.

1 Name and Address

Please enter your last name
Please enter your firstname
Please make a selection
Please enter your address
Please enter your Postcode

1.1 Personal Details

Please add details
/ / Please enter your date of birth
Contact details
Please add details
Please add details
Please add details
Please check your email address
Spouse/Partner
Please enter your spouse's full name
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Next of Kin
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Please make a selection

1.2 Accommodation

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1.3 Employment history

Please include 5 years of employment history within the electrical and energy sector.

Please enter the applicants National Insurance Number
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If you qualify for help through your partner/spouse/husband please fill out the employment section here.

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Please enter the dependants name
/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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Please enter the dependants name
/ / Please enter a valid date of birth
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Applicant/Family/Dependent Health Issues - relating to this application

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1.6 HM Armed Forces

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Please enter a Service/Branch
Please enter the number
Please enter rank
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1.7 Other Organisations Approached

Please make a selection
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Please enter a Name of Association
Please enter a purpose
Please enter an outcome
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Please enter a Name of Association
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Please enter a Name of Association
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Please enter a Name of Association
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1.8 General Information

In this section please tell us the problem in which you need help, supplying us with as much information as possible. Consider the help you need and how you think we may be able to assist

Please enter the details

1.9 Income and Expenditure

Please ensure you add your Income per week

If field is mandatory (*) please input 0 if you do not recieve described fund

No. in family 1 2 3 4 5 6 7
Food & General 70.00 105.00 140.00 175.00 190.00 205.00 220.00
Clothing 10.00 20.00 30.00 40.00 50.00 60.00 70.00
Incidentals 20.00 28.00 36.00 44.00 52.00 60.00 68

Employment

Please only include numbers
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Other Income

Please only include numbers
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Other Charitable Funds

Please enter the source name
Please only include numbers

Service Pensions

Please only user numbers
Please only include numbers

Retirement Pensions

Please only user numbers
Please only user numbers

Sickness Benefits

Please only include numbers
Please only user numbers
Please only user numbers

Bereavement Benefits

Please only include numbers
Please only user numbers

Disability Benefits

Please only user numbers
Please only user numbers
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Please only user numbers

Means Tested Benefits

Please only user numbers
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Please only user numbers
Please only user numbers
Please only user numbers
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Please only user numbers
Please only user numbers
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Please only user numbers

Expenditure per week

If you have no costs please input 0

Residence

Please only user numbers
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Please only user numbers
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Please use numbers only

Insurance

Please only include numbers
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Medical

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Household

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Car Expenses

Please only include numbers
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Fares

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Total sums of money in your...

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Total sums of money for your partner/spouse...

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2.1 Debts

Please select one
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As you have indicated that you have debts, please complete all relevant details using fields below.

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Other debt information

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2.2 GP Details (If you are applying for mental health support only)

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Submit your supporting information with Lightning

We’ve introduced a new way for you to verify your financial situation by quickly and securely connecting your bank accounts, and uploading your supporting documents, through our trusted partner, Lightning.

Connecting your accounts replaces the need for you to upload bank statements with a safer and easier digital process. It may also help us to review your situation more quickly and give you a decision sooner.

You will also need to upload the following supporting documents, as are relevant, on Lightning:

    Letter(s) from the DWP regarding benefits/pensions/tax credits
  • 3 months occupational or private pension payslips
  • 3 months payslips
  • (For accounts that are not online) full bank statements for 3 months for all accounts
  • If application is for mobility or disability equipment or adaptations then it is likely that an Occupational Therapist report will be required and this can be discussed on receipt of the application.

After you have submitted this application, you will receive an email from Lightning with a secure link to guide you through the quick and safe connection and upload process. Emails will be sent by the end of the next working day. Please remember to check your spam and junk folders.

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Declaration for All Applications

  • I declare that to the best of my knowledge, all questions on this form have been fully and truthfully answered.
  • I understand the information I have provided will be used to process this application for mental health support.
  • I agree that the details on this form may be passed to other agencies, and other charities in the course of this application and such details may be held on their files/databases in accordance with our Privacy Notice
  • I authorise the Electrical Industries Charity to approach other agencies on my behalf.

    • General Data Protection Regulation (GDPR) (EU) 2016/679

  • GDPR defines your rights as an individual in relation to the information held about you and how it may be used.
  • The most important reason for holding the information that you have given us is to process your application for assistance. The Electrical Industries Charity needs to keep your data on a computer and in paper files for this purpose. In some circumstances the Charity may need to share this information with third parties, but only in connection with your application, for example another charity, where an offer may be jointly shared or when the charity is organising third party services for counselling, mental health support and general wellbeing. The information may be updated by yourself, or by a third party working on your behalf, such as a Caseworker.
  • We may also use some of the information for accounting, audit, statistical or research purposes (eg to make sure we are offering the right sort of service), but only internally within the organisation. We will not disclose any of your information outside the Charity other than as mentioned above, unless we are legally obliged to do so, or unless you have given us your prior consent.
  • We undertake to keep your information strictly confidential and to do everything we can to prevent the information being used in any unauthorised or unlawful way.
  • With respect to the more sensitive data, e.g. health issues, which we may hold, we need your explicit consent to do so. Please sign this form to agree to us using your data as explained above. We need your signature in order to process your application.
  • We may send you leaflets about other charities, which we might judge to be useful to you. You have the right to ask us to cease this form of correspondence.
  • You also have the right to request a copy of the information we hold about you; we will provide all of this data except any that refers to another person. The Electrical Industries Charity reserves the right to make a charge for this service.
  • For further information please see the Electrical Industries Charity Privacy Notice.
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On a mobile hold your finger down on the screen inside the box below and move to sign.

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Information Sharing Consent

I, the undersigned hereby give my permission for the Electrical Industries Charity to share personal information with other service providers in connection with my care, including accessing and sharing my medical, and mental health records. I agree to a referral being made to local supportive services in order to support my needs. I understand that the Electrical Industries Charity may hold information gathered about me from various service providers and as such my rights under this will not be affected.

Statement of Consent:

  • I understand that personal information is held about me.
  • I have had the opportunity to discuss the implications of sharing or not sharing information about me.
  • I agree that personal information about me may be shared and gathered from mental health services such as therapists, counsellors, psychologists, psychiatrists and my GP.
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I agree to my information being shared between services.

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On a mobile hold your finger down on the screen inside the box below and move to sign.

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