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Private and confidential Rochdale Fund for Relief in Sickness
NOTES FOR APPLICANTS
1. The Rochdale Fund For Relief in Sickness is a local charity which was set up to help any individual who
requires help as a result of hardship caused by sickness, injury, disability or infirmity. This includes both
physical and mental sickness, or deprivation of a nature likely to impair physical or mental health e.g.
poverty or other adversity.
2. To be eligible to apply for assistance the individual must live in the Borough of Rochdale. This includes
Wardle, Littleborough, Middleton, Heywood, Norden, Birtle, Milnrow and Newhey, but not Whitworth.
3. The Trustees can help by providing:
Medical equipment for hospitals
Equipment for Special Schools
Help for individuals by provision of aids for daily living e.g. wheelchairs, hoists, IT equipment,
adaptations to homes, special leisure equipment, medical aids etc. Also financial assistance
towards the cost of washing machines, cookers, clothing, beds, bedding etc for those with illness
in the family.
Respite in the form of holidays and outings, nursing aid or comfort, help for close relatives to visit
or care for patients.
Other items, services and facilities at the discretion of the Trustees.
All grants are made solely at the discretion of the Trustees.
4. The Trustees may also make grants to other bodies, both statutory and voluntary, to assist them in
providing equipment, services or facilities which may alleviate the suffering, or promote the recovery of,
persons who, as individuals, qualify under paragraphs 1 and 2 above.
5. The Fund cannot help with:
Payment of debts, including utility bills, Council tax, Inland Revenue payments etc.
Hardship not directly relating to, or caused as a result of, sickness.
6. ALL SECTIONS OF THE APPLICATION FORM SHOULD BE COMPLETED IN FULL TO AVOID ANY DELAY.
Application forms should be returned to: Clerk to the Trustees
Susan M Stoney LL.B.
The Old Parsonage
2 St. Mary’s Gate
ROCHDALE OL16 1AP
7. Statutory and voluntary bodies should write to The Clerk to the Trustees with all the appropriate
information.
Page 1 of 4 Printed 12-Nov-19
Private and confidential Rochdale Fund for Relief in Sickness
APPLICATION FOR ASSISTANCE
Please type or write in black Ink and continue overleaf if necessary.
1.APPLICANT’S NAME
2. Married / Single /
Divorced / Widowed / Partner
(Delete as appropriate)
3. AGE
4.APPLICANT’S ADDRESS
5. CONTACT DETAILS (where appropriate):
Phone Number:
Email address:
6. Please list members of your family and/or others living with you, stating relationship.
7. Please give details of the illness causing the hardship (continue overleaf if necessary).
8. What assistance do you require from the Fund? (Continue overleaf if necessary).
9. How much money are you requesting from the Fund? (Please provide copies of estimates if possible)
10. Have you or any members of your family previously received a grant from this or any other Charity?
Please give details.
11. Please list any outstanding debts and the amount of the repayments (incl. loans, credit cards and HP
agreements):
12. Do you receive Housing Benefit? Do you receive Council Tax Rebate?
YES / NO YES / NO
13. Please give any other relevant information you can think of in support of your application
14. The information I have given above is to the best of my knowledge, true and correct and I would ask
the Trustees to consider my application.
Signed: ………....................................................... Date: .............................................
(Where the application is on behalf of a client the Social Worker/Health Visitor etc. should sign)
NOTE: The Income and Expenditure Form (page 3) and the Professional Support form (page 4) MUST also be
completed by all applicants.
Page 2 of 4 Printed 12-Nov-19
Widowed
Partner
Private and confidential Rochdale Fund for Relief in Sickness
Statement of Income and Expenditure
Please complete this page in full and include ALL household income, not just the applicant
WEEKLY EXPENDITURE (£)
Rent
How much do you earn?
State average weekly income OR average
monthly income x12 /52
Mortgage
Council Tax
State Retirement Pension
Insurance
Employers Pensions,
Gas Bill
Widow’s and War widow’s
Pensions
Electricity Bill
Any other pensions
Other Heating
Water Rates
Universal Credit
Travel Costs (inc car and taxis or buses)
Unemployment Benefit
Telephone & mobile phone
Income Support
T.V. Costs (inc. rental, repayments, Sky,
TV Licence, cable etc)
Housing benefit
Loan / HP / Credit Card Payments
Child Benefit
Social Fund Repayments
Sickness or Invalidity Benefit
Maintenance & Child Support
Payments
Family Credit
Housekeeping (food, clothes etc)
Disabled Living Allowance
Attendance Allowance
Mobility Allowance
Widows and Widowed Mothers
Allowance
Any other Benefits
4. CHARITIES
Payments from Charities / voluntary
organizations
5. OTHER INCOME
e.g. Maintenance payments, investments
etc. Please state.
Other (please state)
TOTAL INCOME
TOTAL EXPENDITURE
Page 3 of 4 Printed 12-Nov-19
Private and confidential Rochdale Fund for Relief in Sickness
Professional Support
All applications should be supported by a professional person such as a doctor, social worker or health
visitor.
This page is for the comments of the person supporting this application or acting on behalf of the
applicants. Please state clearly why you are supporting the application and then sign your name
thereafter and include your Agency’s official stamp.
(Please use a separate sheet if required)
Signed__________________________________ Date______________________________
Print Name_______________________________ Occupation ________________________
Contact Tel: ______________________________ Email: ______________________________
Agency’s stamp
Page 4 of 4 Printed 12-Nov-19
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