Personal Information:

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:

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:

Financial Details:

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

Household Income Details:

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date it is signed until I have completed or withdrawn from my course.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

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]