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Do you have any outstanding DEBTS, e.g. credit cards, rent or council tax arrears, water rates, gas/electricity/phone bills? Yes If yes, please give details here and attach copies of the demands for payment

No

Have you ever been made bankrupt or entered into an IVA

If YES please give details and dates

No Yes

Have you ever been cautioned or convicted of a criminal offence or are there any criminal proceedings pending against you?

If you have answered YES to either question, please provide details below:

No Yes

Have you asked the Trust (UUWT) for a grant before? No

Yes

If yes when was this?

Have you applied anywhere else for help with this request?

If yes, who have you approached and what was their response?

No Yes

STATE HERE WHAT YOU NEED, WHY YOU NEED IT, AND THE ESTIMATED COSTS INVOLVED

OFFICE USE ONLY (additional information from interviews, phone calls etc)

OFFICE USE ONLY (details of any previous grants made to this applicant)

Page 3 of 4

(UUWT) GRANT APPLICATION FORM ©SP 02/11 (v10)

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