MIDDLESEX
PROVINCE RELIEF FUND Always to be the best and distinguished above the rest
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Please complete
this form and return it to: |
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Name: |
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Address: |
Post Code: |
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Date
of Birth: |
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Current
age: |
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Marital
Status: |
q
Married |
qSingle |
qWidow/er |
qPartner |
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ARE YOU A
FREEMASON? qYES qNO |
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If
yes: |
PROVINCE: |
LODGE: |
No: |
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ARE
YOU A RELATIVE OF A FREEMASON? qYES qNO IF
SO, WHAT IS YOUR RELATIONSHIP? ................................................................................................................................. |
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DEPENDANTS/CHILDREN |
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Age: qMale q Female |
Age: qMale q Female |
Age: qMale q Female |
Age: qMale q Female |
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ARE
THEY DEPENDENT ARE THEY LIVING WITH YOU |
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WHAT
WAS OR IS YOUR OCCUPATION? |
ARE
YOU A CAR OWNER? YES/ NO
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PROPERTY |
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q ARE
YOU A PROPERTY OWNER
q IS
THE PROPERTY JOINTLY OWNED WHO
IS THE ADDITIONAL OWNER WHAT IS THE PROPERTY VALUE q IS
THE PROPERTY RENTED q WHAT
IS THE MONTHLY RENTAL WHAT IS THE
STANDARD OF DECORATION q EXCELLENT q GOOD q FAIR qPOOR |
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INCOME |
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What
is your annual income?
Do
you have more than one source? q YES q NO Do
you have a pension? q YES q NO How many
pensions?........................................................................... What
amount/s are you receiving? What,
if any, is your capital?
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ARE YOU
RECEIVING OR HAVE YOU REQUESTED ANY ASSISTANCE FROM qANY
LODGE
qGRAND
CHARITY
.
qOTHER
MASONIC CHARITY
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qA NON
MASONIC
CHARITY
. qFAMILY
.
.. qANY
OTHER SOURCE
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LIST ANY STATE
BENEFITS YOU ARE RECEIVING q
PENSION
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.. qDISABILITY
ALLOWANCE
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.. qATTENDANCE
ALLOWANCE
.. qCARERS
ALLOWANCE
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.. qMOBILITY
ALLOWANCE
.
.. qANY
OTHER ALLOWANCE
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LIST ALL REGULAR
OUTGOINGS qMORTGAGE
.. qRENT
.
.. qGAS
.. qELECTRICITY
.. qTELEPHONE
.. qHOME
INSURANCE
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.. qPERSONAL
INSURANCE
.. qCAR
INSURANCE
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.. qROAD
FUND LICENCE
.. qTOTAL
CREDIT CARD LIBILITY
.. qOVERDRAFT
PAYMENTS
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HEALTH: |
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Do
you have any problems/conditions? q YES q NO Please
describe in detail:
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.. Name
of specialist:
. Are
any social services provided?
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Do
you use the services of a carer at home?
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.
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BUILDING WORK: |
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ESTIMATES (1) |
ESTIMATES (2) |
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EQUIPMENT
REQUEST: |
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QUOTES
(1) |
QUOTES
(2) |
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OTHER
USEFUL INFORMATION GENERALLY OR FROM
THE PROVINCIAL ALMONER |
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DETAIL
FULLY THE REQUEST FOR ASSISTANCE: |
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Date
of Application: |
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Signed: |