Fund Application

Personal Details
Name*
First
Email*
Phone*
Preferred contact method*
- Email
- Phone
Date of Birth
Day
Month
Year
Marital status
Address
Street Address City County / State / Region ZIP / Postal Code
Is your home:
- Owned
- Rented
- Mortgaged
- Other
Please explain
Spouse / Partner
Spouse / Partners Name
First
Date of Birth
Day
Month
Year
Dependants
ie children living at home or anyone else who is financially dependent on you. This should include children at university
Dependants
Please list their full name, relationship to you, date of birth and if they live at home with you.

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Eligibility / Employment History
In order to confirm your eligibility, please supply the following information. Please provide documentary evidence of eligible employment (copy of payslip, pension payslip etc). If you do not have any evidence to support eligibility please provide as much detail as possible in the sections below). Please note that if you have previously had assistance from the Fund you do not need to complete this section, please move to Section 3 – Income Details.
Name of Person who is/was employed within the UK Nuclear Industry
First
Name of Employer
eg. Sellafield Ltd, Magnox, UKAEA etc
Dates of employment
Job Title
Pay/Pension Number
Department
Location
Reason for leaving
- Retired
- Resigned
- Ill heath Retired
- Death in Service
- Voluntary Redundancy
- Other
Please Specify
If you are not the above person, please state your relationship to them
Widow, Child etc
Proof of employment enclosed
- Yes
- No
Proof of employment
Accepted file types: jpg, png, pdf, Max. file size: 512 MB.
Other Employment History
This should include any time spent in the armed forces
Other Employment History
Include the name of the employer, nature of the work and date
Spouse / Partner Other Employment History
Include the name of the employer, nature of the work and date

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Debts
Please provide details regarding any debts you and/or your Partner have including the reasons for taking out the debt, total owed, monthly repayment amounts and approximate date the debt should clear. Please include Loans, Credit cards, HP/lease agreements, catalogues, utility bill arrears, HMRC debts, debt management plans and any other organisation that you owe money to. If you are not currently making repayments and if any action is being taken by Creditors, please also provide further detail. Please use the continuation section at the end of this form if required.
Your Loans
Please detail who the loan is with, the reason for the loan, monthly repayments, approximate end date and total amount owed.
Your partners loans
Please detail who the loan is with, the reason for the loan, monthly repayments, approximate end date and total amount owed.
Your Credit cards
Please detail who the credit card is with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Your Partners credit cards
Please detail who the credit card is with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Your Arrears
Please detail who the arrears are with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Your Partners arrears
Please detail who the arrears are with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Your Other debts
ie Debt Management Plan, Car lease agreements, Catalogue, family debts etc Please detail who the debts are with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Your Partners other debts
ie Debt Management Plan, Car lease agreements, Catalogue, family debts etc Please detail who the debts are with, the reason for the debt, monthly repayments, approximate end date and total amount owed.
Have you sought any debt advice?
- Yes
- No
Please provide details

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Additional Information
In order for us to process your application, please provide information regarding your situation and your reasons for applying to the Benevolent Fund. Please be aware that the Fund should be a last resort when all other potential sources of assistance have been exhausted (ie state benefits/disabled facilities grants etc). Please use the continuation section at the end of this form if required.
Details of your current circumstances and difficulties.
Reason for applying to the Benevolent Fund
Details of how you would like us to help
including costs, quotes, estimates if applicable
Please state how you heard about the Fund and if you have applied to the Fund before
Have you applied anywhere else for assistance?
Other charities/benevolent funds/local council etc
- Yes
- No
Please provide details

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Declaration, Consent & Signature
I declare that this form has been completed fully and truthful to the best of my knowledge, providing an accurate representation of my present circumstances.
The Nuclear Industry Benevolent Fund is committed to protecting your privacy. We will only use the information that you provide for the following purposes:
- To contact you regarding your application
- To administer, assess and process your application for assistance
- For accounting purposes in the event that financial assistance is awarded
- To contact you periodically in the future to remind you of your eligibility
Personal data processed for any purpose shall not be kept longer than is necessary for that purpose.
The Fund will not share your information with anyone other than those directly involved in the administration/decision making process.
You have the right to have your data amended/deleted upon request.
A comprehensive version of our privacy policy is available upon request or can be viewed on the Fund’s website www.tnibf.org
I consent to the Fund using and processing my data for the purpose of considering this application:
Applicants signature
If you have provided income details of anyone else living in/contributing to the household, please ask them to sign to give their consent for their income details to be used:
Signature
Comments
This field is for validation purposes and should be left unchanged.

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Personal Details

Spouse / Partner

Dependants

Eligibility / Employment History

Other Employment History

Income Detail

Expenditure Details

Debts

Additional Information

Declaration, Consent & Signature