The Chartered Institute of Legal Executives

Registered under The Charities Act, 1960

Telephone: 01234 841000 KEMPSTON MANOR KEMPSTON, BEDFORD MK42 7AB DX 124780 KEMPSTON 2

The Trustees of The CILEx Benevolent Fund will be happy to consider your application for assistance. In order that they may be aware of all the facts, kindly return this application with the enquiries set out below completed in full. Failure to complete this form and the personal budget form in full and provide the required attachments could result in either a delay in response from the Trustees or possible refusal of assistance.

Consideration will be given for financial assistance towards assisting you with the cost of necessitous bills such as utility bills, disability related bills, care fees or unusual or unexpected bills. Please note the Fund is not able to pay monies towards the general cost of living nor is it able to reimburse you for monies already paid. The Fund is also not able to assist with the costs of joining CILEx, subscription or course fees, discharging outstanding judgment debts, IVA’s or bankruptcy.

1. Please state what the assistance is for: ………………………………………………………………………...

2. Total amount requested £………......

3. Applicant’s name: ………………………………………………………Membership No. ……………………….

4. Applicant’s email address: ...... ……………….Telephone No…………………………………..

5. Applicant’s postal address: ....

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6. Date of Birth: …………………………………..

7. Are you single/married/civil partnership/co-habiting/separated/divorced/widowed: ……………………………………………………………………………..... 8. Are you, or was your husband/wife/civil partner a member of:

The Solicitors’ Managing Clerks Association (SMCA) □

The Chartered Institute of Legal Executives (CILEx) □

9. How many wage earners are in your household?………………………………………………………………..

10. Please provide details of those who depend on you. If you have children, please provide their ages. Please also provide brief details of any disabilities for which disability allowance is paid amongst your dependants.

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11. State the names and addresses of your last two employers, periods of such employ and reason for leaving:

(1) Name of Employer (Present if applicable)……….…………………………………………………………….

Date commenced employment….……………………………………………………………………………...

Date ceased employment ………………………………………………………………………………………

Reason for leaving……………………………………………………………………………………………….

(2) Name of Employer (Previous)…………………………………………………………………………………..

Date commenced employment….……………………………………………………………………………...

Date ceased employment ………………………………………………………………………………………

Reason for leaving ………………………………………………………………………………………………

Please note that the Trustees reserve the right to obtain verification of your employment status with your employer.

12. Are you in employment now? ……….. If no, please state whether you are receiving unemployment benefits and if so, the amount £……………………………………………………………………………………….

13. Have you made an application to any other charity? If so, state:

(a) Which and when …………………………………………………………………………………………………..

(b) Whether your application(s) was/were successful?......

14. Can any family assist you, including your Partner’s family if applicable?......

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15. Please give full details of your savings from all sources and particulars of any investments, deposit accounts etc.

Total Savings £ ……………………………………………. Investments £ ………………………………………… 16. If you have any personal loans, please state the amount the loan was when you took it out, the purpose of the loan, what your monthly payments are and when you expect the loan to be cleared. If you have more than one loan, please advise whether you have sought financial advice on consolidating your loans and what the result was.

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…………………………………………………………………………………………………………………………… 17. If you have any credit card debt, please state the amount on your credit card(s) and whether you have sought financial advice on consolidating your debts and what the result was.

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18. Do you own any other property or a share in a property? If so, please specify.

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19. Any special circumstances which you wish the Trustees to consider:

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20. Where did you learn about the CILEx Benevolent Fund?

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21. Have you made a previous application to the CILEx Benevolent Fund? If so, please state when.

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22. Have you reviewed the Benefits and other Government Help Guide located on the CILEx website to ensure you are in receipt of any state support you are entitled to? Yes/No, if no please visit www.cilex.org.uk

…………………………………………………………………………………………………………………………… The trustees generally do not consider mobile calls, cable packages, clothing, house maintenance, car maintenance and other items of similar nature to be necessitous monthly outgoings. Please do not list these items on your Personal Budget Form.

Please tick which are enclosed and provide full and recent copies (within the last 3 months) of the following:

Council Tax □ Water and sewerage charges □ Ground rent/service charge □ Buildings/content insurance □ Life insurance/pension □ Gas □ Electricity □ Telephone rental □

The particulars stated above set out my position and I declare that the information is true. I attach the Personal Budget Form and declare that the information contained in the Personal Budget Form is a true statement of my household income and expenditure.

Data Protection Act 1998 In order to help you we need to keep a record of your application, which may contain personal data. The law states we must obtain your consent to do this. Everything you tell us will be treated confidentially and will only be used for the purpose of processing your application.

CILEx Group Information Sharing In order to assess your application, the trustees from time to time will need to make enquiries amongst the CILEx Group. The CILEx Group consists of The Chartered Institute of Legal Executives, CILEx Regulation and CILEx Law School.

Signature: …………………………………………….. Date: …………………………………………………… CILEx Benevolent Fund – Personal Budget Form Name: ______Membership No. ______STEP 1 INCOME Monthly STEP 2 OUTGOINGS Figures ONLY Monthly Figures ONLY Wages/salary (GROSS figures) ______Wages/salary (partner or parent) Income Tax (GROSS figures) ______National Insurance Interest from ______savings/investments/Rental Income ______Income Tax (Partner)

Jobseekers Allowance National Insurance (Partner) ______(contributory or non-contributory) ______Mortgage ______Income Support ______Other Mortgages ______Tax Credit/Child Tax Credit ______Retirement/Work Pension/Pension Rent Credit ______Council Tax Child Benefit ______Water and Sewerage Employment and Support Charges ______Allowance (ESA) ______Ground rent/Service Charge ______Maintenance: ______Self ______Buildings/contents insurance ______Partner ______Child ______Life Insurance/Pension ______

DLA/Attendance/Carer’s Allowance ______Gas Non-dependant contribution ______Electricity ______Other State Benefits: Housing Benefit ______Food ______Council Tax Benefit ______Other (please specify) ______Maintenance payments ______

Total Income £ ______Travel Fares (please provide ______receipts) ______School meals ______Telephone rental

Child minding ______

Total Outgoings £ ______

N.B. Please do not list any additional items that are not stated on this form