To apply for a grant you can either display and print the pdf file John_Holford_Application_Form.pdf or complete all the boxes below and press [Send]. Before filling in this on-line form please prepare any supporting documents in Word .doc format and attach them to your submission where prompted. Please be aware that incomplete applications may be rejected by the Trustees.


THE JOHN HOLFORD CHARITY

APPLICATION FORM

for

The Relief of Persons who are in conditions of need, hardship or distress.


Applicants must be resident in either:

[A] The parish of Clutton

[B] The parish of Middlewich

[C] The Borough of Congleton

[D] The Ecclesiastical parish of Astbury


1. Surname
2. Christian names
3. Address
4.
5.
6. Date of birth (ddmmyy)
7. List all dependant children
and give details of age and
whether they are living with
You (name, age, yes or no)
8. Do you have any other
relatives dependant on you?
9a. If YES, state relationship
and reason for dependence
9b. State weekly amount
contributed by you
10. Does any such dependant
receive Income from any
other source?
11. If YES, give details and
amount
12a. Are you working?
12b. Is your spouse working?
If Yes to 12a state:
13ia. Your occupation
13ib. Name and address of
employer
13ic. Gross annual wage *1
If Yes to 12b state:
13iia. Spouse’s occupation
13iib. Name and address of
Spouse’s employer
13iic. Gross annual wage *1
14. Are you retired?
If Yes to 14 state:
14a. Amount of National
Pension received for
yourself
14b. Amount of National
Pension received for
your spouse
14c. Amount of all National
Supplementary Pension
received
14d. Amount of any other
private pensions receive
by you and your spouse
15a. If you are not working
state reasons
15b. Are you receiving any
State assistance? *2
16. If YES  give amount
17a. If you do not own your
own home, state weekly rent
paid
17b. Amount paid in rates
18a. Do you have Capital? *3
18ai. What is the value of
your Capital? *3
18aii. What is the value of
your spouse’s Capital? *3
State below the value of any
dwelling you and your spouse
own, after deducting the
outstanding mortgage
18bi. The property you live in
18bii. Any other property
18biii. Annual mortgage
repayment
19. Other income, give
Details *4
20. How long have you lived
in any of the places specified
at the beginning of the form?
21. State for what reason you
apply for financial relief and
give all relevant information
which will assist the Trustees
when considering your
Application *5
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Certificate of your earnings
Certificate of Spouse’s earnings
Supporting Letter 1
Supporting Letter 2
Other Supporting Document
22. The Trustees reserve the right to make such further enquiries as they think fit to enable them to give
full consideration to your application and your completed application form will be construed as authorising
the Trustees to make such further enquiries
Please ensure all relevant questions have been answered before clicking [Send]

*1

You will need to attach to this form a certificate of earnings signed by your employer, or if Self Employed, by your Accountant


*2

Sickness benefit, unemployment benefit, redundancy pay, etc.


*3

Capital is cash, savings or investments, other than your house

*4

From rents, dividends interest, annuities, Building Society & bank deposits etc


*5

You can attach a separate Word.doc document below