ABOUT YOUR NURSING CAREER

DECLARATION OF YOUR WEEKLY/MONTHLY INCOME & EXPENDITURE

  • STEP 1
  • STEP 2
  • Step 3
  • STEP 4
  • STEP 5
  • STEP 6
  • STEP 7
  • STEP 8
  • STEP 9

START APPLICATION

Are you a Registered Nurse who is, or have been employed for example as a district nurse, health visitor, school nurse, community specialist nurse, community psychiatric nurse, learning disability nurse, or a community midwife and hold a bank account solely in your own name?

Unfortunately we are unable to help you. Please visit our Links page to view a list of other organisations that may be able to help.

PERSONAL DETAILS OF NURSE

Title

First Name

Last Name

Maiden Name

NMC/UKCC or GNC No

DOB

Home Address Including Postcode

Preferred Telephone No

Email Address

THIRD PARTY APPLICANT

Are you making this application on behalf of the Registered Nurse?

No action needed – please proceed to the next step.

Full Name

Address Including Postcode

Relationship to nurse: if you are a relation please send a scan or photo of a letter confirming your relationship signed by a suitable authority.

Organisation Name

Upload your letter

Max. size: 10.0 MB

TRAINING HISTORY

Name of your nurse training school/college/university, Dates and Qualifications

Name of community nursing education college/university, Dates and Qualifications

COMMUNITY NURSING EMPLOYMENT HISTORY ONLY

Name of Community Nursing Authority, Dates and Post Held/Job Title

ABOUT YOUR PRESENT OR PREVIOUS EMPLOYMENT AND/OR RETIREMENT

Are you currently in employment?

Please state reason

Are you currently retired?

What date did you retire?

Were you retired on health grounds?

HOUSING STATUS

Do you live alone or share accommodation?

DETAILS OF DEPENDENTS

Name

Age

Relationship

Living at Home?

DO YOU WANT TO ADD ANOTHER DEPENDENT?

Name

Age

Relationship

Living at Home?

DO YOU WANT TO ADD ANOTHER DEPENDENT?

Name

Age

Relationship

Living at Home?

DO YOU WANT TO ADD ANOTHER DEPENDENT?

Name

Age

Relationship

Living at Home?

DO YOU WANT TO ADD ANOTHER DEPENDENT?

Name

Age

Relationship

Living at Home?

DO YOU WANT TO ADD ANOTHER DEPENDENT?

Name

Age

Relationship

Living at Home?

Do you have savings in any of the following? Please state amounts (£’s only)

Current Bank Account

Deposit Bank Account

Building Society Accounts

Post Office Account

Stocks and Shares

Tessa’s and ISA’s

Other Assets

Please advise us of the details of your bank account for use if you are awarded a grant; this needs to be a single account held in your name

Name of Bank

Account Name

Sort Code

Account Number

INCOME

Salary (Per Week/Month)

Statutory Sick Pay (Per Week/Month)

State Retirement Pension (Per Week/Month)

Income Support (Per Week/Month)

Child Benefit (Per Week/Month)

Family Credit (Per Week/Month)

Housing Benefit (Per Week/Month)

DSS Benefit/State Benefit/Other (Per Week/Month)

Council Tax Rebate (Per Week/Month)

NHS Pension (Per Week/Month)

Occupational Pension (Per Week/Month)

Income from Investments (Per Week/Month)

Regular Income from Charitable Funds (Per Week/Month)

Income of Spouse/Partner (Per Week/Month)

Income from Lodgers (Per Week/Month)

Income from Family (Per Week/Month)

Other (Per Week/Month)

EXPENDITURE

Please only list debts and loans which you are solely responsible for.

Mortgage/Rent (Per Week/Month)

Council Tax (Per Week/Month)

Water Rates (Per Week/Month)

Gas (Per Week/Month)

Electric (Per Week/Month)

Telephone (Per Week/Month)

Television (Per Week/Month)

Food (Per Week/Month)

Clothing & Necessities (Per Week/Month)

Insurance (Per Week/Month)

Travel/Car Expenses (Per Week/Month)

Debt Repayments (Per Week/Month)

Loan Repayments (Per Week/Month)

Other (Per Week/Month)

REASON FOR APPLICATION

Why do you think you may be eligible for consideration of a grant from the 1930 Fund? Include details of your need.

FINAL STEP

Amount of funding requested (£)

How did you hear about the 1930 Fund For District Nurses?

Have you applied before?

Date of Grant Received

Applicant No

Amount's Received (£)

Are you currently applying or have you applied to any other charitable trust in the last 3 years?

Name of Trust

Date Applied

Amount Requested (£)

Amount Received (£)

WOULD YOU LIKE TO ADD ANOTHER?

Name of Trust

Date Appled

Amount Requested (£)

Amount Received (£)

WOULD YOU LIKE TO ADD ANOTHER?

Name of Trust

Date Applied

Amount Requested (£)

Amount Received (£)

If you need to add more, please pout them in the Extra Notes section at the end of this form.

Would any of your existing benefits be affected by this grant?

Please explain how and why

EVIDENCE REQUIRED

Untitled Document

Please provide the following information:
• A recent payslip, if applicable.
• Copies of certificates of training and development courses relevant to community practice.

If you are requesting assistance for a specific item or service, please would you provide scans of at least two written quotes.

Upload Evidence

Max. size: 10.0 MB

Upload Evidence

Max. size: 10.0 MB

Upload Evidence

Max. size: 10.0 MB

Upload Evidence

Max. size: 10.0 MB

Extra Notes

Declaration

Please note our Privacy Policy; By clicking I ACCEPT on this form you confirm you have read, understood and consent for us to use your information in the manner as stated therein.

Name of Applicant or Authority

I ACCEPT

Please type your name to sign the form

Date

If your application does not fall within our criteria will you give us permission to send your details to another charity if we feel they may be able to help you?