MIDDLESEX PROVINCE RELIEF FUND Always to be the best and distinguished above the rest

Return form to : Mrs. J.H.Baker, Five Oaks, London Road, Rickmansworth, Herts. WD3 1JT

Full Name:
Address:	Post Code:
Date of Birth: & Age			Telephone: Mobile:
Marital Status:	q Married	qSingle	qWidow/er	qPartner

ARE YOU A FREEMASON? qYES qNO
If yes:	PROVINCE:	LODGE:	No:
ARE YOU A RELATIVE OF A FREEMASON? qYES qNO IF SO, WHAT IS YOUR RELATIONSHIP? .................................................................................................................................

DEPENDANTS/CHILDREN
Age: . . . . . . . . . . qMale q Female Dependant? Living with you?	Age: . . . . . . . . . qMale q Female Dependant? Living with you?	Age: . . . . . . . . . qMale q Female Dependant? Living with you?	Age: . . . . . . . . . qMale q Female Dependant? Living with you?

YOUR OCCUPATION, OR FORMER OCCUPATION IF RETIRED?

PROPERTY

q ARE YOU A PROPERTY OWNER? q DO YOU OWN (OR PART OWN) MORE THAN ONE PROPERTY?

q IS THE PROPERTY JOINTLY OWNED? q IS THE ADDITIONAL PROPERTY JOINTLY OWNED?

IF SO, THE ADDITIONAL OWNER : . . . . . . IF SO, THE ADDITIONAL OWNER : . . . . . . . . . . . . .

q THE PROPERTY VALUE £ q ADDITIONAL PROPERTY VALUE £. . . . .

q IF PROPERTY RENTED, YEARLY RENTAL £ q IF ADDITIONAL PROPERTY RENTED, YEARLY RENTAL £

WHAT IS THE MAIN PROPERTY CONDITION q EXCELLENT q GOOD q FAIR qPOOR

AND WHAT IS THE STANDARD OF DECORATION q EXCELLENT q GOOD q FAIR qPOOR

INCOME (indicate “N” for nett or “G” for Gross, and whether yearly, monthly, or weekly Y, M, or W)

OWN PARTNERS

STATE PENSION £ STATE PENSION £

OWN PENSIONS £ OWN PENSIONS £

COMPANY PENSIONS £ COMPANY PENSIONS £

FROM EMPLOYMENT £ OWN EMPLOYMENT £

INTEREST ON SAVINGS £ INTEREST ON SAVINGS £

DIVIDENDS £ DIVIDENDS £

TOTAL STATE BENEFITS £ TOTAL STATE BENEFITS £

OTHER INCOME £ OTHER INCOME £

(State Source) (State Source)

TOTAL INCOME £ PARTNERS TOTAL INCOME £

CAPITAL & SAVINGS

OWN PARTNERS

CURRENT ACCOUNT £ CURRENT ACCOUNT £

DEPOSIT ACCOUNT £ DEPOSIT ACCOUNT £

BUILDING SOCIETY £ BUILDING SOCIETY £

POST OFFICE ACCOUNT £ POST OFFICE ACCOUNT £

RETIREMENT BONDS £ RETIREMENT BONDS £

SAVINGS CERTIFICATES £ SAVINGS CERTIFICATES £

SHARES £ SHARES £

PEP / ISAs £ PEP / ISAs £

OTHER CAPITAL/SAVINGS £ OTHER CAPITAL/SAVINGS £

STATE BENEFITS: – (Indicate if amount is weekly, monthly, or yearly W, M, or Y )

q YOUR PENSION. . . . . . £ YOUR PARTNERS STATE PENSION £

qDISABILITY ALLOWANCE. £ IF PARTNER RECEIVES DISABILITY ALLOWANCE £

qATTENDANCE ALLOWANCE £ IF PARTNER RECEIVES ATTENDANCE ALLOWANCE £

qCARERS ALLOWANCE … £ IF PARTNER RECEIVES CARERS ALLOWANCE £

qMOBILITY ALLOWANCE… £ IF PARTNER RECEIVES MOBILITY ALLOWANCE £

qANY OTHER BENEFIT PAID £ IF PARTNER RECEIVES OTHER BENEFIT £

ARE YOU RECEIVING OR HAVE YOU REQUESTED ANY ASSISTANCE FROM

qANY LODGE

IF SO, THE LODGE NAME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PURPOSE OF GRANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AMOUNT £

qGRAND CHARITY

PURPOSE OF GRANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AMOUNT £

qOTHER MASONIC CHARITY…

IF SO, NAME OF CHARITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PURPOSE OF GRANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AMOUNT £

q NON MASONIC CHARITY…(name of charity) . . . . . . . . . . . . . . . . . . . . . . . . . AMOUNT £

PURPOSE OF GRANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AMOUNT £

qFAMILY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AMOUNT £

qNAME ANY OTHER SOURCE OF ASSISTANCE . . . . . . . . . . . . . . . . . . . . . . . . . . AMOUNT £

OUTGOINGS (Indicate if the amount is weekly, monthly, or yearly W, M, or Y )

qMORTGAGE……………………………….£ qRENT………………………………£.

qGAS………………………………………….£ qELECTRICITY……………………£

qWATER RATES………………………….£