The Dempster Trust Application Form

Personal details

Forename *

Surname *

Date of birth

Email address *

Confirm email address *

Address line 1

Address line 2

Town/City

County

Postcode

Home telephone number

Mobile telephone number

Total weekly income

Weekly expenditure

State benefits (please state which)

Number of adults living at this address

Number of children living at this address

Ages of children

Have you previously applied for help from the Dempster Trust?
Evidence of income (wage slips, benefits letters, etc.)

Upload scanned wage slips or evidence of benefits received. You can select multiple files (PDF, JPG, PNG, GIF).

Reason for the application (eg financial situation and health issues)

Referrer details

Please provide details of a person who can support your application.

Name *

Occupation *

Contact number *

Date

Assistance required

Please state the type of assistance required (eg domestic equipment/appliances, school uniform, beds and bedding, care alarms, wheelchairs etc).

Declaration

I confirm that the above information and details are correct.
I agree to The Dempster Trust collecting, using, storing and sharing your personal information in accordance with our Privacy Policy.