Application for A Short Welfare Break - RAF Benevolent Fund

Private & Confidential
Reference
Registered Charity No. 226686 (in England and Wales) (SC037673 in Scotland)
Application for A Short Welfare Break
(to be completed by Welfare Officer / Helper)
THIS IS AN APPLICATION FOR:
Registered Charity No. 207327
Royal Air Force
Benevolent Fund
THE HEART OF THE RAF FAMILY
Flowerdown House
55 Beach Road Western Super Mare BS23 1BH
Rothbury House
West End Rothbury NE65 7TT
Princess Marina House
Seafield Road, Rustington, West Sussex BN16 2JG
Other
Richard Peck House
1 St Thomas Rd Lytham St Annes FY8 1JL
A. DETAILS OF SERVICE PERSON ON WHOM ELIGIBILTY IS BASED
Applicant Yes No
Surname
Maiden Name
Forenames
Date of Birth
D D M M Y Y
Religion
National Insurance No
RAF Service No Rank Branch/Trade
From D D M M Y Y To D D M M Y Y NHS No
War Disability Pensioner No Yes % Disability If Deceased, Date of Death
D D M M Y Y
Service Details Verified No Yes By What Means
B. DETAILS OF ELIGIBLE APPLICANT (IF NOT ABOVE) Date of Birth D D M M Y Y
Surname
Date of Marriage
D D M M Y Y
Forenames
National Insurance No
Relationship to Person at Section A
NHS No
C. DETAILS OF ANY OTHER PERSON ACCOMPANYING APPLICANT
Surname
Relationship to Applicant
Forenames
NHS No
Date of Birth
D D M M Y Y
National Insurance No
D. ADDRESS OF APPLICANT
Postcode
Telephone
0
Type of accommodation (house, flat, caravan, furnished rooms etc)
Condition of tenure (owner occupier, council or private tenancy etc)
April 2012

E. APPLICANTS WEEKLY HOUSEHOLD INCOME & EXPENDITURE (verified from relevant documents)
Is the applicant, to the best of your knowledge, in receipt of all applicable state benefits, rebates and allowances?
Yes No What action is being taken?
EXPENDITURE Verified Weekly Arrears INCOME
Weekly
£ p £ p £ p
Rent (less Housing benefit)
Earnings of Applicant (inc overtime but less Tax and NI)
Mortgage
Council Tax
Housekeeping
Gardener
Electricity
Gas
Water Rates
Other Fuels
Insurance (not NI)
Television
Satellite
Telephone
Broadband
Taxi/Bus fares
Car
Scooter/EPV costs
Personal/Debts/loans/HP
Hairdresser
House Repairs
Pets (state if guide/assistance dog)
Window Cleaner
Cleaner
Carer
Prescriptions
Alternative therapy
Other (please specify)
Earnings of spouse/partner
Job Seekers/Income Support
Statutory Sick/Maternity Pay
Maintenance received
State Retirement Pension
Service Pension
Occupational Pension
War Disablement Pension ( %)
Pensions – Spouse
Disablement Pension ( %)
Incapacity Benefit/Employment Support Allowance
Widows Pension (War/NI)
Child Benefit/Special Allowance
Working Tax Credit
Universal Credits
Industrial Injuries Disablement Benefit
Severe Disablement Allowance
Disability Living Allowance – Care Component
Disability Living Allowance – Mobility Component
Attendance Allowance
Disability Working Allowance
Pension Credit
Carers Allowances
Other income (give details)
Total
Total
Savings/Capital/Investments Please show amount of savings eg. Bank, Building Society, National Savings etc £
Any other long-term investments? State what they are £
F. SHORT WELFARE BREAK FOR APPLICATIONS TO PMH
Period of stay requested is ONE WEEK TWO WEEKS The preferred day of arrival is
State briefly the need for such a break
TUESDAY
WEDNESDAY
I/We need
days’ notice or I/We can accept a cancellation at short notice
THURSDAY
April 2012

DETAILS OF NEXT OF KIN NOT ACCOMPANYING APPLICANT(s) TO BE CONTACTED IN AN EMERGENCY
Name
Relationship
Address
Postcode
Telephone
0
G. PREVIOUS WELFARE BREAKS
Please provide details of previous breaks
Dates Where stayed Dates Where stayed
The current fees are £ per person per week
Total Fees £
Applicants contribution £
Branch contribution £
Balance £
Mode of travel Car Coach Train
Cost of Travel £
Applicant’s contribution £
Branch Contribution £
Balance £
If the RAF Association or RAF Benevolent Fund is unable to provide accommodation to meet your needs, would you accept a
referral to a recommended alternative.
NO go to Section J
YES go to Section H
H. SHORT WELFARE BREAK IN A PRIVATE HOME
(completed form to Area Welfare Officer)
TOTAL
Name of Home Costings £ Persons @ per £
week add, partner
is charged at
different rates £ £
Period of Stay FROM
TO
D D M M Y Y
D D M M Y Y
Applicant’s contributions £
Other Contributions £
Grant/Subsidy required £
I. HELP AT HOME
Domiciliary/Day Care
Specify assistance required
Have Social Services undertaken an assessment? No Yes
Name of Social Services
Case Manager (if known)
Tel No.
0
Now go to Section J
FOR OFFICE USE ONLY
Cost hours per week for weeks £
Applicants Contribution £
Subsidy Required £
April 2012

J. EMPLOYMENT RECORD Please give details of current and previous employment
Employer From To Type of Employment
K. CERTIFICATE (to be read out to the applicant)
H I declare that the information I have given on this form is correct to the best of my knowledge.
H I agree that the information supplied on this form may be shared with voluntary or charitable organisations and relevant statutory
agencies for the purpose of furthering my application for assistance.
H I agree that the information supplied on this form may be shared with the Ministry of Defence and its agencies, including
Service Personnel and Veterans Agency, for the purpose of verifying my service in the Armed Forces.
H I agree that information collected as part of the application process may be retained so that any future
applications may be speedily processed, and that data generated may be used for follow up assistance,
statistical and research purposes.
Signature
Date
D D M M Y Y
L. REPORT OF WELFARE OFFICER/HELPER AND RECOMMENDATION
This statement should give a description of the circumstances of the applicant, what the need is and the opinion of the Welfare
Officer/Helper. Please use an additional sheet, if necessary.
Each applicant has been advised to complete the pre-admission assessment form and requested to forward it to the home. Yes
Signature Mr/Mrs/Miss/Mrs/Other Name
Address
Postcode
0
Branch Telephone Date
D D M M Y Y
April 2012