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. Applicant Details Surname Forenames NI Number Address Date of Birth Telephone 2. Particulars of spouse/partner Surname Forenames Address NI Number (if different from Date of Birth applicant) Place of Birth 3. Employment History within F1 From To Reason for leaving: 4. Details of employment of spouse/partner Name of employer Nature of employment From To Type of business 5. Income & Expenditure Monthly income £ Monthly expenditure £ Arrears Earnings Mortgage Wages/salary (Applicant) Rent Wages/salary (Spouse/Partner) Council Tax Pensions (Applicant) Utility Bills Private Retirement Pension Insurances (house & life combined) State Retirement Pension Housekeeping Pension (Spouse/Partner) Car costs Private Retirement Pension Prescription costs State Retirement Pension Liability Debts Any other Income Debit & Credit Cards TOTAL INCOME TOTAL EXPENDITURE 6. Savings and capital £ Applicant and spouse/partner’s total savings (incl capital, investments, building society, bank) 7. Previous assistance from The Grand Prix Trust Date Amount Purpose of Award Comments 8. Assistance required (To be completed by office) Type of Assistance Estimated Cost Contribution from client and family members 9. Other Agencies that client has been signposted to by The Grand Prix Trust (To be completed by office) 1. 2. 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 10. 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) .