Apply to Other Programs

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    Personal Information:









    SingleMarriedDivorcedSeparatedWidowedCo-Habiting

    Contact Number:



    Please note: We will inform you of your application outcome by email to your personal email
    account, however we will also send you a text message to inform you your decision has been sent.

    Residency:

    YesNo
    If Yes go to (f), if no continue to (b)

    YesNo
    If Yes go to (f), if no continue to (c)

    YesNo
    If Yes go to (f), if no continue to (d)

    YesNo
    If Yes go to (f), if no continue to (e)


    YesNo

    Bank Details:

    (Payment will be made into this account. Please remember to bring evidence of these details)




    Financial Need:

    (You must complete this section to indicate what assistance you potentially need)

    Please tick the categories you wish to be assessed for assistance with:

    Additional Living costsRental CostsChildcare Costs


    Financial Details:

    Please answer the following questions, evidence may be required to support your answers:
    Question

    Answer

    Evidence

    YesNo
    Birth Certificate

    YesNo
    Childs Birth Cert

    YesNo
    Marriage Certificate

    YesNo
    Evidence from relevant Health
    Trust or social worker

    Household Income Details:






    SingleMarriedDivorcedSeparatedWidowedCo-Habiting

    Income Source

    Person 1

    Person 2

    Evidence required

    Last 3 payslips or latest P60

    Latest verified Accounts

    Verified Accounts

    HMRC Award Notification

    Award Letter or Bank Statement

    DHSS Letter or Bank Statement

    DHSS Letter or Bank Statement

    DHSS Letter or Bank Statement

    DHSS Letter or Bank Statement

    DHSS Letter or Bank Statement

    Verified data from official source

    Applicant Consent

    We need you to consent to communicate with any appropriate private and governmental agencies in
    order to obtain and release information (both verbally and in written format) to enable a complete
    and fair assessment of your application. All information shared will be handled in a confidential
    manner.

    I understand that I may revoke my consent at any time and this revocation must be delivered in
    written format to The Liberation Foundation admin team. This consent form will be valid from the
    date it is signed until I have completed or withdrawn from my course.



    Applicant Statement

    You can use this section to explain any/all of the following: reason for financial difficulties or income
    and expenditure. Please provide documentary evidence where possible to support your statement.

    Applicant’s Declaration:

    (you must read and sign this section)

    I certify that all particulars given by me on this form are correct and that all relevant information has
    been included. I understand the information provided will be handled in accordance with the
    General Data Protection Regulation. I understand that it is my responsibility to supply all the relevant
    documents to support my application, as well as any additional information that the panel requires in
    a timely manner. I understand that the onus is on me to prove my need for financial assistance.
    If I receive Widow / Widower Support funds from The Liberation Foundation I undertake to:

    • Advise The Liberation Foundation immediately if I cease to need the support and I will pay
      back the amount awarded to me.
    • Refund any over payment, which may have occurred for whatever reason by the Liberation
      Foundation
    By ticking this box, you are confirming that you have read the Widow / Widower Fund terms and conditions document and agree with the terms stated.



    *Referee Verification

    (to be completed by Referee only)

    i (Referee Name) certify that the applicant is a widow / widower.
    Relationship of Referee to applicant [applicant-name]