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Application Form IN CONFIDENCE WHEN COMPLETED Application for Assistance Form All sections to be completed before application can be processed Please return to: Sally Oliver MIW (Acc.) 26 The Grove Butlocks Heath Netley Abbey Southampton SO31 5FP E: [email protected] 1 IN CONFIDENCE WHEN COMPLETED 1. Applicant Details Surname Forenames NI Number Address Date of Birth Place of Birth Phone Single/married/divorced/widowed/partner Accommodation type (house, flat, etc) Owned/local authority/private rent Property Details Value of currently resided property: Mortgage Outstanding on current property: Details of 2nd Property (if applicable): Outstanding Mortgage on 2nd property: 2. Particulars of spouse/partner Surname Forenames Address NI Number (if different from Date of Birth applicant) Place of Birth 3. Particulars of all dependents Living at Relationship to Employed/unemployed Name Age home or away applicant or at school/university 4. Employment History within F1 From To Reason for leaving: 2 IN CONFIDENCE WHEN COMPLETED 5. Details of employment of spouse/partner Name of employer Nature of employment From To Type of business 6. Income & Expenditure Monthly income £ Monthly expenditure £ Arrears Earnings Mortgage Wages/salary (Applicant) Second Mortgage Wages/salary (Spouse/Partner) Rent Sub-letting/boarders etc Council tax Pensions (Applicant) Gas Private Retirement Pension Electricity State Retirement Pension Magistrates court fines State Widows/Bereavement Allowance Maintenance/CSA payments Pension (Spouse/Partner) Water rates/sewage charges Private Retirement Pension TV/Video/Satellite/Cable State Retirement Pension Ground rent/Service charge State Widows/Bereavement Allowance Building/contents insurance State Benefits Other housing costs JSA/Income Support (Applicant) Mortgage endowment policy JSA/Income Support (Spouse/Partner) Life insurance Disability related benefits, please specify: Other insurance(s) Other fuel (incl oil, coal, calor gas) Pension contributions Housekeeping Family/child benefits - specify Car costs Universal Credit Travel costs (incl taxis and buses) Personal Ind Payment - Applicant School meals/meals at work Personal Ind Payment – Spouse/Ptr Clothing All other income (eg. Contributions from other Prescription/health costs household members) Child Maintenance Carer/childcare costs Liabilities/debts (from section 9) Other expenditure (please specify) Telephone TOTAL INCOME TOTAL EXPENDITURE 7. Savings and capital £ Applicant and spouse/partner’s total savings (incl capital, investments, building society, bank) 3 IN CONFIDENCE WHEN COMPLETED 8. State Benefits Is the Applicant in receipt of Housing Benefit? Is the Applicant in receipt of Council Tax Benefit? Are enquiries about other benefits being made? If YES, which benefits? 9. Liabilities/debts Date of Amount of Weekly Total arrears Amount Creditors purchase contract instalments of instalments outstanding 10. Previous assistance from The Grand Prix Trust Date Amount Purpose of Award Comments 11. Assistance required (To be completed by office) Type of Assistance Estimated Cost Contribution from client and family members 12. Other Agencies that client has been signposted to by The Grand Prix Trust (To be completed by office) 1. 2. 3. 4 IN CONFIDENCE WHEN COMPLETED I agree that the details on this form may be passed in full, and in confidence, to the Appeals Committee of The Grand Prix Trust as highlighted below. Please sign below to confirm that you are happy for your information to be shared. If The Grand Prix Trust think that it may be beneficial to inform the remaining Trustees listed below (your name would be anonymous to them), or to contact other Organisations on your behalf, this will be discussed and agreed with you separately. Declaration I declare that the information I have given in this application is, to the best of my knowledge, correct. I understand that the information I have provided will be used to process this application, and retained so that any future applications may be speedily processed. Signature of client: Date: Signature of applicant’s Date: spouse/partner: Who Can Be Approached Signed by Client Appeals Committee of Grand Prix Trust: Remaining Trustees of Grand Prix Trust: Other Organisations as deemed necessary to assist with your application: Trustees Martin Brundle – Chairman of the Trustees (Appeals Committee) Sir Patrick Head – Co Founder of Williams F1 (Appeals Committee) Michael Jakeman – Managing Director, MJ Tech Limited (Appeals Committee) James Allen - President, Motorsport Network Chris Bliss – Partner, Rawlinson & Hunter Chartered Accountants Ross Brawn OBE – Formula One Management Karin Fink – Head of Global Motorsport Marketing Peter Hamlyn - Medical Advisor Mark Smith – Director of Greenlight Sports Jonathan Wheatley – Red Bull Racing 5 IN CONFIDENCE WHEN COMPLETED 13. Additional Information If there are any other circumstances concerning your financial situation you would like the Trustees to consider do please write below: (Continue on a separate sheet if necessary) 6 .
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