CIMA Benevolent Fund
(registered charity 261114)
Please return the completed form to:
CIMA Benevolent Fund Secretary
CIMA
The Helicon
One South Place
London
EC2M 2RB
benevolent.fund@cimaglobal.com
PERSONAL DETAILS
Surname
First names
Address
Telephone
postcode
home
mobile
Email
Date of birth
Marital status
CIMA MEMBERSHIP
Name of member or former member
CIMA contact ID
If you are not the member, what is your
relationship to the member ?
Is the member also a member of any
other professional bodies ? Which ?
FAMILY DETAILS: YOUR PARTNER
Name
Date of birth
Occupation
Membership of
professional
bodies
FAMILY DETAILS: YOUR CHILDREN AND OTHER DEPENDANTS
Name
Date of birth
Relationship
to you
In full-time
education or
working ?
Living with
you ?
1
YOUR EMPLOYMENT HISTORY
Current employer
Name
Address
Your job title
Date this employment started
Previous employers in last
10 years
Name
Your job title
Dates of this employment
YOUR PARTNER’S EMPLOYMENT HISTORY
Current employer
Name
Address
Job title
Date this employment started
Previous employers in last
10 years
Name
Job title
Dates of this employment
HEALTH
Please give details of any illness or disability relevant to your application.
APPLICATIONS TO OTHER CHARITIES
Please give details of any other charities to which you are applying or have applied.
Name of charity
Date of your application Assistance received
2
YOUR HOUSEHOLD INCOME
Yourself
Your partner
Office
use
only
Earnings – monthly
net of income tax
and National
Insurance
Pensions – monthly
private/occupational
state
Welfare benefits –
weekly
jobseeker’s allowance
Welfare benefits –
monthly
employment and
support allowance
statutory sick pay
incapacity benefit
income support
disability living
allowance
carer’s allowance
bereavement
allowance
widowed parent’s
allowance
pension credit
attendance allowance
child benefit
other
working tax credit
child tax credit
housing benefit
council tax benefit
Investment income –
monthly
interest
dividends
other
Rents received –
monthly
Help from family –
monthly
maintenance
other
Help from other
charities - monthly
Any other income
LESS any tax you
have to pay if any of
the figures are gross
TOTAL
3
YOUR HOUSEHOLD EXPENDITURE
Frequency
(weekly,
monthly,
annual)
Yourself
Your partner
Office
use
only
Rent
Mortgage
Care home fees
Service charges
Council tax
Water charges
Gas
Electricity
Other fuel
Food and household goods
Home help / domestic care
Clothing and footwear
Telephone / mobile / internet
TV licence and rental
Pets
Motoring costs – tax
- insurance
- petrol
Other travel costs
Insurances – building and
contents
- medical
- life
- other
Maintenance paid
Pension payments
Debt servicing – bank loans
- credit cards
- hire purchase
- other
Other regular expenditure
(please specify)
TOTAL
4
YOUR CAPITAL
Please show the value of these assets.
Bank and building society deposits
Stocks and shares / PEPs / ISAs
Other savings
Yourself
Your partner
Yourself
Your partner
Owned property – main home
- other
Other (please specify)
YOUR DEBTS
Please show the amounts outstanding.
Mortgage
Bank loans
Bank overdraft
Credit cards
Hire purchase loans
Arrears on household bills
Loans from family and friends
Other (please specify)
ADDITIONAL INFORMATION
Please provide any additional information in support of your application, such as any
recent changes in your circumstances or changes which are about to occur.
CONSENT (To be signed by both you and your partner)
I/we declare that, to the best of my/our knowledge, the information provided above is
accurate.
I/we consent to the processing by CIMA staff of the data I/we have provided on this form and
in other communications with CIMA in compliance with the Data Protection Act 1998. I/we
consent to the disclosure of the same data by CIMA staff to CIMA representatives, where
necessary for purposes of assessing my/our application for assistance, and to other charities
and organisations who may be able to assist me/us. I/we further consent to the processing of
the data by these representatives, charities and organisations.
Signed ……………………………….. (applicant)
Signed ……………………………….. (applicant’s partner)
Date …………..
Date …………..
5