British Benevolent Fund Spain Referral Form
British Benevolent Fund Spain Referral Form The Person Being Referred First Name Surname Tel. No. Email Address 1 Address 2 Town/City County Postcode Country Birth Date Birth Place Marital Status Resident in Spain? N.I.E No. N.I.E date Padron district Padron Date Spanish Health Card YES/NO Is it valid? EHIC? YES/NO Is it valid? YES/NO The Person Making The Referral (leave blank if you are referring yourself) First Name Surname Tel. No. Email Address 1 Address 2 Town/City County Postcode Country Relationship to person being referred Is the person being referred a British national? Passport number If the person being referred is a dependant of a British national please describe below the nature of the relationship and give the name and contact details of the British national. Does the person being referred give their consent to this referral? (Please ensure they sign the data protection section at the end) Please forward the completed referral form to: info@ britishbenevolentfund.org British Benevolent Fund Spain Referral Form Case Details Please give details of the problem faced by the person being referred. Please include as much background information as possible such as how the person being referred got into this situation, what steps they have taken to help themselves, who else is effected by the situation, the consequences faced by the person being referred should help not be available, any circumstances that make the individual particularly vulnerable. Please forward the completed referral form to: info@ britishbenevolentfund.org British Benevolent Fund Spain Referral Form Pre Referral Checks What checks were made to assess the above case is genuine. What proof was provided to demonstrate the individual has insufficient funds to help themselves (please complete separate income/expenditure form if possible) Has an approach been made to the competent authority where applicable? Please give details: Does the person being referred have a UK military background or is dependent on someone with a UK military background? (If yes please refer to RBL or Age Concern España) Please give details of approaches made to any relevant local or national charities, and local fund raising groups such as The Lions and The Rotary Club. Please forward the completed referral form to: info@ britishbenevolentfund.org British Benevolent Fund Spain Referral Form Please give details of any immediate family of the person being referred. Have the family been contacted. If not, why not? What help can the family provide? If no or little help available please explain why. Please forward the completed referral form to: info@ britishbenevolentfund.org British Benevolent Fund Spain Referral Form What assistance does the person being referred seek from the BBF. For financial assistance please be clear on how much is sought and what it will pay for. Please explain how this assistance will resolve or alleviate the situation. Payment Please give details of where payment should be made to. Please email you referral to info@britishbenevolentfund.org Data Protection Act - I am aware that: The British Benevolent Fund of Madrid will create and maintain computer and paper records based on the information I have provided in this form. The information and records created will be used for the sole purpose of applying for financial aid from The British Benevolent Fund of Madrid. The information will not be shared or disclosed with any external source without my written consent. Where an application for financial aid has been referred to the British Benevolent Fund from a third party organisation this will be taken as written permission to share information on that specific case with the said third party. All records are held by the secretary of the British Benevolent Fund of Madrid for as long as they continue to provide financial support, and for up to 7 years afterwards. I can request a copy of my records from the secretary at any time by sending an email to info@britishbenevolentfund.org. If I feel the information held in the records is incorrect or inaccurate, requests for changes or deletions should also be made in writing to the Executive Committee of the British Benevolent Fund of Madrid at info@britishbenevolentfund.org. The Executive Committee meets once a month (except during Christmas and Easter) and a response will be made following the next committee meeting. Name of Applicant: Date: Signature: Please forward the completed referral form to: info@ britishbenevolentfund.org Appendix 1 - Income and Expenditure Wk/Mth/Yr Income Euro/£ WAGES/SALARY Your wages Partner’s Wages Other NON WAGE INCOME Child Maintenance State Pension Occupational Pension Private Pension Other PROPERTY INCOME Sub let, Boarders Holiday lets Second property Other INVESTMENT INCOME % on savings Stock Dividends Director Fees Other UK STATE BENEFITS (please specify) ESA/JSA/IS/IB PIP/DLA/AA/IB HB & CTB Tax Credits Winter Fuel Allowance Maternity Allowance Carer’s Allowance Other SPANISH BENEFITS Unemployment Maternity Leave Sick Pay Invalidity Pension Ley de Dependencia Other FAMILY CONTRIBUTIONS (Give details) OTHER (Give details) Total Income CAPITAL ASSETS Asset House/Home Second/Holiday Home Car, bike etc Savings Stocks/Shares Other Investments Valuables Other Total Assets Value Details DEBTS & LIABILITIES Debt Mortgage Bank loans Credit/Store Cards Car/Hire Purchase Other Total Debts Value Repayments Expenditure Wk/Mth/Yr Euro/£ HOUSING COSTS Mortgage/Rent Urbanisation Fees Property Insurance Maintenance Other UTILITIES Gas Electricity Water Other fuel Telephone Land Mobile Phone Internet/wifi Cable/Sat TV Other TAX AND OTHER DEDUCTIONS Local Taxes Income Tax Social Security Child Maintenance Life Insurance Pension Other (supervivencia) TRAVEL COSTS Car Insurance Car MOT Car Tax Car maintenance Petrol/Diesel Public transport Taxis HOUSEKEEPING Food Cleaning Materials Toilettries Clothes Shoes Other HEALTH AND BEAUTY Medicine Dentist Medical Specialists Hairdresser Other DEPENDANTS Childminder/Carer Pocketmoney School costs Other ENTERTAINMENT Eating/Drinking Out Going Out (theatre..) Gymn, social clubs Day trips Holidays Books, DVDs, Games Other OTHER EXPENDITURE (Please specify) Total Expenditure Please forward the completed referral form to: info@ britishbenevolentfund.org
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