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