Grant Application Form

Please complete the following form and submit
I am making this application in the best interests of the applicant and the personal information I am providing about the applicant is accurate to my knowledge. I have explained to the applicant that, in making this referral, I am sharing their personal data, including health information, and the applicant has agreed to this. I have explained that Independence at Home will be using the information to assess their grant application.
I confirm I have explained the application process and have the permission of the applicant to share all the information included within this grant application. (Please note that we are unable to consider grant applications where you do not have permission to share such information.)

Click here to view our privacy policy
Hide Section - Part 1 Applicant Details

Part 1 Applicant Details

  
  
  
Hide Section - Part 2 Referrer Contact Details

Part 2 Referrer Contact Details

  
  
Hide Section - Part 3(A) Referrer Case of Need

Part 3(A) Referrer Case of Need

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Hide Section - Part 3 (B) Medical Confirmation to back up Referral

Part 3 (B) Medical Confirmation to back up Referral

If the referrer is not a qualified health or social care professional we need to have written confirmation of the applicant’s medical diagnosis
Please attach a copy letter or report from a qualified health or social care professional in support of your application confirming the applicant’s medical diagnosis. This must be recent and be written on their letterhead paper
Hide Section - Part 4 Household Details

Part 4 Household Details

  
    
  
Hide Section - Part 5 Total Weekly Household Income

Part 5 Total Weekly Household Income

Please note:-  
If the client is married or living with partner and sharing household costs please identify the total weekly income including sources  
If client is over 18 and still living with parents please identify the total weekly income for that individual including sources  
If the client is under 18 please identify the total including weekly income including sources for the parent(s)  
  
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Hide Section - Part 6 Other Funding

Part 6 Other Funding

    
        
    
      
Hide Section - Part 7 Previous Grant/s

Part 7 Previous Grant/s

  
  
Hide Section - Part 8 Purpose of Grant and Amount Requested

Part 8 Purpose of Grant and Amount Requested

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Please note we require a quotation on the proposed supplier/contractor's letterhead paper  
  
Please note that our grants are modest and range between £200-£500 depending on the item of equipment or building work required  
Hide Section - Part 9 Payee details for the grant

Part 9 Payee details for the grant

Please note that GRANTS CAN ONLY BE MADE PAYABLE TO THE SUPPLIER OR THE REFERRING ORGANISATION and NOT TO THE CLIENT  
  

For cheque payments we need the name of the account of the supplier or referring organisation  
For BACS payments we need bank account details of the supplier or referring organisation  

*** NB: Complete Sort Code, Account Number and Payment Ref below if payment by BACS *****
*** NB: Please DO NOT enter hyphens in Sort Code *****
  
  
  
Hide Section - Part 10 Data Protection

Part 10 Data Protection

The confidentiality of your personal information is of paramount concern to us. We are registered with the Information Controller’s Office as a Data Controller under the Data Protection Act 1998 and will process and hold your information in accordance with legislation
  
IAH Charity Company trading as Independence at Home, registered in England and Wales. Company Number 7620400 Registered Charity Number 1141758. Registered Office-Congress House, 14 Lyon Road, Harrow, HA1 2EN
Please ensure you have all your supporting documents available to upload before pressing the 'submit button'

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