SIN Application Forms

Name

Address

Post Code

Telephone

Email *

Date Of Birth

Please tell us about your disability and how this affects you? *

For what purpose do you require a Grant? – How will the provision improve your health care? *

Name of Medical Professional supporting your application? Please arrange for a letter to be sent to us.

Telephone

Has an assessment of your need ever been made by Social or Health Services?

If YES, when was the assessment carried out?

And what was the result?

If NO, why not?

Please describe the equipment required. Please send written quotations as soon as possible. If you are applying for a scooter or electric wheelchair, we will need a completed assessment form to demonstrate safe use, storage and maintenance before we can consider your application.

Income Salary *

DLA Care / PIP Daily Living *

Income Support *

Pension *

Savings *

Other Benefits e.g. Universal Credits, Tax Credits *

Total Annual Income If in excess of £30,000 please explain why you are not able to self-fund. *

What is the total cost of the equipment? *

Amount requested from Catalyst? *

What contribution could you make? Please note we never fully fund any equipment, a reasonable contribution will be expected. *

If you are completing this form for the applicant, please give your name, address, relationship and telephone number – Your Name

Address

Post Code

Email *

Relationship *

Telephone *

DECLARATION – I declare that the information given in this form is correct & complete and I am aware that this application will be discussed with relevant health professionals and/or other charities in order to help Colchester Catalyst Charity make a decision on my application.