Financial Assistance form

A. Are you or have you been an MRCVS or a dependant of an MRCVS? Please provide details here:
Name of MRCVS
Date of birth of MRCVS
Date & place of qualification
If you are a dependant please specify your relation to MRCVS
B. Are you aware that Vetlife is not able to help with private health or education costs?
- Yes
- No
C. Have you checked with the Department of Works & Pensions or your local Citizens Advice Bureau that you are claiming your full entitlement of State benefits?
- Yes
- No
D. Have you approached your family for financial support?
- Yes
- No
E. Do you give permission for Vetlife to obtain professional debt and benefits advice on your behalf?
- Yes
- No

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REFERENCES

You may choose to provide the names and contact details of two referees who have given their permission to be contacted by Vetlife (if possible these should be members of the veterinary profession)
1. Name & Address
2. Name & Address
Where did you hear about us?

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DOCUMENTS REQUIRED IN ORDER TO ASSESSS YOUR APPLICATION

We will need relevant documentary evidence of your income and expenditure:
This must include the last three months’ statements for all bank accounts and credit cards held by you and/or your partner, plus the following documents:

• A copy of a letter from the DWP with details of any State benefits you are receiving
• A recent mortgage/rent statement
• Copies of letters from creditors regarding arrears, where you have outstanding debts

It is not necessary to send copies of utility bills or Council tax bills. Photocopies or scanned documents are normally acceptable. All documents will be returned to you by post.

ABOUT YOU AND YOUR SPOUSE/PARTNER
1. Your Details
Name*
First name Family name
Date of Birth
Title*
Age
Marital status
Marital status
Home address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Place of birth
Phone
Telephone (mobile)
Email*
RCVS registration number if applicable
If a grant is awarded, it may be credited direct to your bank or building society account. Please complete the table below to allow this to be done.
Name of bank/building society
Account name
Branch address
Sort code number
Account number
Building society reference no.

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2. Details of your spouse/partner (if applicable)
Spouse/partner?*
- Yes
- No
Name
First name Family name
Date of Birth
Title
Age
Marital status
Home address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email
RCVS registration number if applicable

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3. Details of sons, daughters and any contributing adults living at home
Name Age or date of birth Relationship to applicant Employed or at school Weekly income if employed Weekly contribution to household

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ABOUT YOUR FINANCES

4. Details of incomeIndicate net weekly income after tax etc
State retirement pension
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Net earnings (after tax etc)
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Widows/widowers benefits
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Maternity/paternity benefits
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Occupational/private pension
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Other pension(s)
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Child benefit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Working tax credit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Council tax reduction
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Housing benefit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Income Support
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Jobseeker’s Allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Mortgage interest payments from income support or Job Seeker’s Allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Pension credit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Statutory sick pay
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Industrial Injuries Disablement Benefit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Incapacity benefit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Employment and support allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Severe disablement allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Carer’s allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Attendance allowance
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Disability living allowance - mobility
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Disability living allowance - care
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Personal independence payment – daily living
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Personal independent payment - mobility
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Universal credit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Working tax credit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Child tax credit
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Income from savings and investments
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Property or rental income
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)
Any other income including support from other charities, court maintenance orders, child support agency payments, insurance or financial support from friends or family (please specify)
Applicant £ Partner £ Payment frequency (weekly/monthly/ annually)

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5. Savings and capital
Current account balance
Yourself Partner
Deposit or savings account(s) balance
Yourself Partner
National savings/premium bonds
Yourself Partner
Shares (market value)
Yourself Partner
Other savings (please specify)
Yourself Partner
Investment property value
Yourself Partner
Life insurance or endowment policies (including date of maturity)
Yourself Partner
Car (with make, model and year)
Yourself Partner

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6. Details of housing
Property details*
Give approximate market value of property
Give approximate amount contents insured for
Date of Purchase
Amount of mortgage/s
Remaining length of mortgage/s
Name of Lender
In whose name is the property?
Which Council Tax band (e.g. A) does your home come under?
Are you the tenant?
- Yes
- No
Council owned?
- Yes
- No
Family owned?
- Yes
- No
Please give details of other property/ownership:

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7. Expenditure
Mortgage repayments
£ Payment Frequency (weekly/monthly/ annually)
Mortgage protection insurance
£ Payment Frequency (weekly/monthly/ annually)
Mortgage protection insurance
£ Payment Frequency (weekly/monthly/ annually)
Ground rent
£ Payment Frequency (weekly/monthly/ annually)
Rent
£ Payment Frequency (weekly/monthly/ annually)
Nursing or Residential Home Fees
£ Payment Frequency (weekly/monthly/ annually)
(Annually)
Council Tax (Annually)
£ Payment Frequency (weekly/monthly/ annually)
Water Rates
£ Payment Frequency (weekly/monthly/ annually)
Sewerage Charges
£ Payment Frequency (weekly/monthly/ annually)
Electricity
£ Payment Frequency (weekly/monthly/ annually)
Gas
£ Payment Frequency (weekly/monthly/ annually)
Other fuels
£ Payment Frequency (weekly/monthly/ annually)
TV Hire (if applicable) and Licence Fee
£ Payment Frequency (weekly/monthly/ annually)
Insurance – Personal, e.g. Life, Endowment, etc - House and Contents - Practice
£ Payment Frequency (weekly/monthly/ annually)
TV Hire (if applicable) and Licence Fee
£ Payment Frequency (weekly/monthly/ annually)
(Quarterly)
Telephone
£ Payment Frequency (weekly/monthly/ annually)
Housekeeping – food, clothing etc
£ Payment Frequency (weekly/monthly/ annually)
Domestic Help & Carers
£ Payment Frequency (weekly/monthly/ annually)
Travelling – Motor Vehicle (Tax, Insurance, Repairs, Petrol)
£ Payment Frequency (weekly/monthly/ annually)
Other travelling costs
£ Payment Frequency (weekly/monthly/ annually)
Other expenditure not including debt repayments in section 8 below (Give details)
£ Payment Frequency (weekly/monthly/ annually)

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8. Details of any debts
Rent or mortgage
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Council tax
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Service charge
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Gas or electricity
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Telephone
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Credit card(s)
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Store card(s)
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Friends/relatives
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Bank overdraft
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Bank loan(s)
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Social fund loan
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
Other (please specify)
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue
FOR VETERINARY SURGEONS ONLY Please give details of any outstanding liabilities in connection with the practice for which you are responsible (including income tax) and indicate the extent of your personal responsibility
Applicant £ total owed Partner £ total owed Applicant £ monthly repayment Partner £ monthly repayment Payments overdue

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9. Reason for grant application

Please tell us why you need financial assistance. You may wish to continue on a separate piece of paper.
Reason for grant application

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10. Declaration

I DECLARE that the information given is complete and accurate. I authorise Vetlife to seek confirmation from my Bank, Building Society, the Department of Work & Pensions or the Local Authority. I UNDERTAKE to inform Vetlife of any subsequent change in my financial circumstances as soon as it occurs.
Declaration*
- I consent to Vetlife processing and storing my information for the purposes of this application.
- Please tick this box if you allow Vetlife to confer, in confidence, with other charities or organisations to seek help or make enquiries on your behalf (we will only do this if we consider this to be to your advantage).
- I have enclosed documentary evidence in support of all income and savings.
APPEALS

If you disagree with the decision of the Grant Awards Panel you are entitled to submit an appeal in writing within 14 days of the decision. This should include any additional evidence, or mitigating circumstances which will be considered when reviewing their decision. If you wish to make a complaint, you may submit a complaint to the Complaints Committee, which is appointed by the Board.

VETLIFE COMPLAINTS POLICY

Vetlife is committed to providing the best possible service. There will, however, be times when things go wrong. We want to know when this happens. We take your comments and complaints seriously as they help us to improve our service in the future.

How to Complain

1. In the first instance, please send your complaint to:

By Mail:The Complaints Panel, Vetlife, 7 Mansfield Street, London W1G 9NQ

By E Mail:[email protected]

2. You should receive an acknowledgement letter from the Complaints Panel within 5 working days and a full written response within 30 working days.

3. If you are not satisfied with the response provided from the Complaints Committee, you should ask for your complaint to be forwarded to the attention of the Vetlife President, who will ensure that it is passed to an external adjudicator who will provide a final decision on the complaint.

DATA PROTECTION NOTICE TO VETLIFE BENEFICIARIES

The information you have provided on this form will be used to assess your application and to manage any subsequent grant. We use a computerised database to manage our grants and your information will be stored here securely for the length of your grant and for accounting purposes.

You can ask to see the information we hold about you at any time by writing to [email protected].

We take your privacy seriously and will not share your information, other than to manage and administer your grant.

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Name	Age or date of birth	Relationship to applicant	Employed or at school	Weekly income if employed	Weekly contribution to household

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Contact Vetlife Office: 020 7908 6385 • [email protected]