Application Form for a Television or Radio on Behalf of an Individual

Transcription

1 Please read the Guidance Notes available on the WaveLength website before making the application, and ensure that the Applicant can provide the relevant information. Incomplete applications which omit information requested cannot be accepted. 1. Applicant s Details Please provide the contact details of the person on whose behalf you are making this application. The address given here should be the address where the equipment will be delivered and installed. If applying for a television, the Applicant should be able to provide his or her own television licence. There are a number of different schemes available to help those who might find this financially difficult; see Guidance Notes. Title: Mr/Mrs/Ms/Miss/ First names Surname Previous names Date of Birth: National Insurance Number: Address: County: Postcode: Country (please circle): England / Northern Ireland / Wales / Scotland Phone number: Applicant s Declaration: I agree to provide feedback upon equipment provided and its benefits, to help WaveLength understand and promote the effectiveness of its work. I agree to take all reasonable steps to look after any equipment, provide feedback and co-operation with any third parties WaveLength is working with. For the purpose of the Data Protection Act 1998, I agree to the information given to WaveLength being kept by them and shared with third parties to provide me and others with services. Signed: Dated: FOR OFFICE USE ONLY Date received: Date approved: Approved by: TV /Radio case no: 1

2 2. Referee Details: Name of Referee: Mr /Mrs/Ms/Miss Job Title: Name of Referring Organisation/Body (if any): Department and Address: County: Postcode: Country (please circle): England / Northern Ireland / Wales / Scotland Telephone number: address: ( address must be provided) Fax number: Mobile number: Referee Declaration I declare that the information provided is true to the best of my knowledge and I will undertake to inform WaveLength of any changes in circumstances such as the Applicant s change of address or death, where reasonably possible. I agree to provide feedback upon equipment provided and its benefits, to help WaveLength understand and promote the effectiveness of its work and receive communications from WaveLength. For the purpose of the Data Protection Act 1998, I agree to the information given to WaveLength being kept by them and used in providing a service. Signed: Dated: 3. Please tell us how you heard about us. 4a). Has the Applicant applied to WaveLength before? (please circle): YES / NO 4b) If YES please give the date and outcome of the application: 5. UK residency status (please see Guidance Notes for documents required): Questions 6 9: Applicant s Accommodation 2

3 6. Is the Applicant s accommodation (please circle): Rented/ Owned by the occupier? 7. In what type of accommodation does the Applicant live? E.g. house, downstairs flat, sheltered or supported housing 8a). Is the Applicant a tenant of a social organisation such as a Housing Association / Social Landlord? (Please circle or specify in space provided) b) If so, please provide details of the organisation, including any particular specialism (eg elderly care, mental health, moving out of homelessness), and an explanation why they or you cannot supply the equipment. Organisation name Specialism Why they or you cannot supply a television/radio. (Please do not say not within your remit or something the organisation does not do. See notes) Questions 9 11: Delivery and Accomodation 9. Is the Applicant disabled? Please tell us about the nature of the disability, and whether it may affect the delivery or installation of equipment. 10. Contact name / phone number for the best person to discuss installation arrangements 11a). Where will the equipment be located in the accommodation (ie the room and floor)? b) Could the location pose difficulties to delivery and installation? Questions 12 14: Further Applicant Information 3

4 12. Information in support of application: why does the Applicant need a television or radio? Why and how would this improve the Applicant s life? How will it help them to move forward over the next three years? 13a). Has the Applicant had a television or radio before? (please circle): YES / NO b) If Yes, when and what happened to it? 14a) Has the Applicant received help through the Digital Switchover Help Scheme? (please circle): YES / NO b) If so, what sort of help? Or, if not, why was no help received? Questions 15 17: Equipment Provision 15. Which equipment is being requested? Please select one box to tick. (Please note: WaveLength aims to help and support people with their first set, but an aerial is required for all sets). 19 digital TV with Freeview Radio 16a). Which type of aerial is currently in place?: b) Is there an external or communal aerial at the property? (please circle): YES / NO c) Does the Applicant have a set-top aerial? (please circle): YES / NO c) Does the Applicant have (please circle): Sky/ Virgin/ cable/ satellite or subscription TV?: 4

5 d) If yes to above, please state who pays for the service: e) If the Applicant does not currently have an aerial, how will they provide one to use with their TV set? 17a) Does the Applicant have a current TV licence? (Persons over 75 are exempt): YES / NO / Applicant is over 75 b) If the Applicant does not have a TV licence, how will they provide one to use with their TV set? c) Please give expiry date of current/last licence. d) Is the Applicant in receipt of a TV licence under any other scheme (Sheltered Housing, Residential Care etc)?: YES/ NO If Yes, please name the scheme here: e) Is the Applicant part of a TV pre-payment plan? (please circle): YES / NO f) Is the Applicant registered blind, or entitled to a reduction in the licence fee for any other reason? (please circle): YES/ NO. If so, please provide a copy of relevant registration. Questions 18 20: Loneliness and Isolation (We expect the Applicant to be very restricted to their own home and loneliness and isolation to be the result of age, disability or life-limiting illness.) 18a). Does the Applicant live alone? (please circle): YES / NO b) If No, please provide details of all people living with the Applicant. Name Age Relationship to the Applicant Employment Benefits received and amount Weekly financial contribution to household 5

6 19. How much contact does the Applicant have with family and friends who are not living with them eg, on a weekly, monthly, yearly basis? 20. Please describe what practical and financial support the family provides. If none, please tell us why there is no support. Questions 21 24: Financial Situation of Applicant and Household 21. Employment past and present (please indicate which) 22. What savings and non-employment income does the Applicant have? Savings Capital holdings Investments Equity release 23. What debts and loans does the Applicant have? Creditor Reason for/nature of debt Amount 6

7 24. List of all benefits currently received by Applicant. Please attach copy of current award letters. Benefit Name Amount per week or month Time Period & Review date 25. Applications to other Charities on behalf of this individual or household: Charity Reason for / Objective of application Amount requested or given Outcome (if known) 26. In order to process this application, please also provide us with copies of 3 months of all bank/building society/post office account statements, and copies of all current benefit award letters. All pages should be included. Checklist If you do not provide all information requested, we cannot process this application. All sections of form completed Form signed by Applicant and Referee 7

8 Copy of birth certificate, passport or documents referring to residency status enclosed (necessary for all applications) Copy of current benefit award letters enclosed Copies of 3 months of all bank/building society/post office account statements enclosed Have read the Guidance Notes provided in order to complete form accurately 8