Application - Liverpool Merchants Guild

0151 703 1080
info@liverpoolmerchantsguild.org.uk

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Step 1 of 13 - What are you applying for from the Guild?

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Please choose the type of support you are applying for from Liverpool Merchants' Guild:*
Also, if eligible, would you like to be considered for a regular payment:
- Yes
- No

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How did you hear about the Liverpool Merchants’ Guild?*
- Introduction via an advice/support org/Intermediary who is assisting me to make this application
- Internet/Search Engine
- Word of Mouth
How would you prefer us to make contact with you if we require further information when assessing your application?*
- By Post
- By Email
- By Phone

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As you are being assisted through this process....
Please include the contact details for the agency which is assisting you to make this application:
Please include the contact details for the agency which is assisting you to make this application
Organisation:*
Staff Name:*
Job Title:*
Staff Email:*
Phone Number:
Do you wish to keep your intermediary up to date with your application progress?
If introduction/support in applying is via an intermediary/advice agency/support organisation, do we have your permission to keep them updated about your application, make further enquiries about your application and/or inform them of any award made to you?
- Yes, keep my intermediary up to date.

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Section 2: Your Personal Details
Title:*
First Name:*
Surname:*
Home Phone Number*
Mobile Phone Number*
Email Address*
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Number of years you have lived in Merseyside*
If your current address is NOT in Merseyside please supply details of previous addresses showing at least 15 years continuous residence in the area. Please attach a separate sheet if necessary.
Previous Addresses
Address From To
Is your home:*
if rented is your landlord*
- Private Landlord
- Housing Association
Please provide the name of your landlord*
Does your rent or service charges payable include any of the following:
- Heating
- Manager Services
Date of Birth*
Current marital status*
Please give details of your next of kin or personal representative
Name
Address
Telephone
Email
Do we have your permission to liaise with your next of kin/personal representative if necessary?*
- Yes
- No

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Section 3: Your Employment and Employment History
Are you Currently Working?*
- Yes
- No
Occupation Category*
Job Title*
Organisation*
Length of Service
Brief Description of Duties
Please confirm that The Liverpool Merchants’ Guild has your permission to verify the detail provided above with your present employer. Failure to give permission will mean that your application cannot proceed.
- Yes
- No
If you are currently unemployed and are under your state pension age, what is preventing you from being able to work and what are you doing to overcome this?
Past Employment History - Please provide details of ALL past employment giving as much detail as possible for each entry. Use the + icon to add further periods of employment. You may upload a copy of your CV below if you prefer. FAILURE TO PROVIDE THIS INFORMATION MAY MEAN THAT YOUR APPLICATION CANNOT PROCEED.
Past Employment History
Employer Position Held From To Duties
Upload your CV (optional)
Please confirm that The Liverpool Merchants’ Guild has your permission to verify the detail provided above with your past employer(s). Failure to give permission will mean that your application cannot proceed*
- Yes
- No

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Section 4: Your Household - Who Lives with you?
What is your current living arrangement?*
- Living Alone
- Living With Partner (Wife/Husband)
- Living With Children
- Other
Please give full name(s), relationship and occupation(s)
How many children live with you?*
Ages of children under 18*
How many other adults live with you?*
Ages of adults*
Age
Are any of the above employed? Please give details below
Are you disabled?*
- Yes
- No
What is the nature of your disability?
Is anyone else in your household disabled?*
- Yes
- No
If YES, please tell us who and the nature of their disability
Besides you and your wife/husband/partner does any other person contribute to household expenditure?*
- Yes
- No
If YES how much is their weekly contribution

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Section 5: One Off Grants
Liverpool Merchants’ Guild will consider applications for grants for items of exceptional expenditure, equipment or adaptations to support independent living. Should you wish to apply for a grant please complete this section of the Application Form.
THE MAXIMUM GRANT AVAILABLE IS £6000.
Purpose Of Grant*
Please provide a brief description of the item(s) required and the benefits to you.
Item Description Benefit To You
Amount of grant requested*
Please provide details of a minimum of 2 supplier's estimates showing the full cost.*
Supplier Estimate
Estimate Details
Professional Assessment*
Has an assessment been carried out by a qualified person (e.g. Occupational Therapist/Social Worker/GP) which confirms the need for the above item(s) and their suitability for use by you?
As you have said yes, please attach a copy of the assessment report to this application.
Accepted file types: pdf, doc, docx, jpg, jpeg, png, gif.
Other Funding*
Have you made any applications to other organisations for funding in respect of the item(s) set out above?
If YES please provide details of the organisations approached and the amounts of any awards made*
Organisation Award Made

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Section 6: Your Financial Information – ALL applicants should complete this section
If we assess your application as suitable for further consideration, we will ask for supporting documentation when we inform you if we are progressing your application. Our staged approach aims to reduce the amount of information required at this stage.
Please enter details of gross income before deduction of income tax
State Pension (Per Week)
State Pension - Yourself*
State Pension - Partner*
Pension Credit (Per Week)
Pension Credit - Yourself*
Pension Credit - Partner*
Universal Credit(Per Month)
Universal Credit - Yourself*
Universal Credit - Partner*
JSA/ESA(Per Week)
JSA/ESA - Yourself*
JSA/ESA - Partner*
Carer’s Allowance(Per Week)
Carer’s Allowance - Yourself*
Carer’s Allowance - Partner*
Care Component/Daily Living(Per Week)
Mobility(Per Week)
Care Component/Daily Living - Yourself*
Care Component/Daily Living - Partner*
Mobility - Yourself*
Mobility - Partner*
Other State Benefit (Please Specify)
Specify Payments Yourself Your Partner
Occupational Pension (Per Annum)
Occupational Pension - Yourself*
Occupational Pension - Partner*
Bank/ B.Society Interest (Per Annum)
Bank/ B.Society Interest - Yourself*
Bank/ B.Society Interest - Partner*
Dividends (Per Annum)
Dividends - Yourself*
Dividends - Partner*
From Family/Relatives (Per Annum)
From Family/Relatives - Yours*
From Family/Relatives - Partner*
Other Income including income from employment (Please specify)
Specify Payments Yourself Your Partner

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Financial Outgoings
Council Tax (Per Annum)
Council Tax Outgoing (Yearly)*
Mortgage Interest Payable (Per Annum)
Mortgage Outgoing (Yearly)*
Water Rates (Per Annum)
Water Rates (Yearly)*
Rent (Per Week)
Rent Outgoing (Weekly)*
Housing Benefit Received (Per Week)
Housing Benefit Received (Weekly)*
Balance of mortgage outstanding
Balance of mortgage outstanding*
Nursing Or Residential Home Fees (Per Week)
Nursing Or Residential Home Fees (Weekly)*

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Capital
Cash in bank(s) - give details of ALL accounts held either in sole or joint names.
Bank Name Amount £
Cash in building societies - give details of building society(s) accounts either in sole or joint names
Building Society Name Amount £
Stocks and shares (give details of shareholding either in sole or joint names)
Stock/Share Details Amount £
Premium Bonds/Savings Certificates (either in sole or joint names)
Certificates Amount £
Any other capital either in sole or joint names (please give full details)
Other Amount £

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In order to comply with Charities Common Reporting Standard (CRS) Regulations please confirm whether or not you are resident in the UK for income tax purposes*
Please note you are automatically resident in the UK for income tax purposes if you spent 183 or more days in the UK in the tax year REGARDLESS OF WHETHER OR NOT YOU PAY TAX.
Does anyone hold Power of Attorney over your Financial Affairs?*
(A Power of Attorney is a legal document giving someone else the authority to take actions or make decisions on your behalf. It enables you to choose a person/ or people (called an attorney) to deal with your property and affairs).
Name
Address
Email
Telephone

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Further Information
Please use the box below if you wish to provide further details/information about why you are applying to the Liverpool Merchants’ Guild for support
Further Information

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Form of Declaration
I declare that the statements I have made on this application form are true and correct to the best of my knowledge and belief.
Signature*
Date*
I agree for Liverpool Merchants Guild to store and process the information entered into this application to aide in progressing the application process. This includes passing related information to third-parties when appropriate.*
More information available in our Privacy Policy
- I accept these terms & conditions
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Email
This field is for validation purposes and should be left unchanged.

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Call 0151 703 1080, email info@liverpoolmerchantsguild.org.uk or request a callback

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Secretaries: Monetta LLP
110 – 114 Duke Street
Liverpool
L1 5AG

T: 0151 703 1080
F: 0151 703 1085
E: info@liverpoolmerchantsguild.org.uk

© The Liverpool Merchants' Guild
A charitable company limited by guarantee, registered in England & Wales number 1091649
Registered Charity number 206454
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