You can review your answers to the form questions here. If you need to make any changes, please click Amend. It is important to check that all the financial fields have been entered correctly. Once you have made any amendments necessary, please Review again before Submitting. If you are happy with your application, click 'Submit' to send it to us. Once you have clicked the 'Submit' button you will not be able to make any further amendments to your application.

 

Please ensure that you quote your Online Application Reference if you email or post your documents to us.

If you do not receive a confirmation email from us within 12 hours of completing your application, please log back in using the same email address and password, as this probably means you have not completed your application and it has not been submitted.

 

(If you have come to this screen via the View all questions before registering link on the Welcome screen - the above will not apply until you register and complete the application).

A1
*Your Name
Please enter your full title if you are a serving/former member of the clergy eg: Canon, Reverend, Reverend Doctor etc.
(Title, First name, Surname)

         
A2
If you have ever been known by another surname (e.g. maiden name or different birth name), please provide your previous surname here.

      
A3
Your address
*Address1:      
  Address2:    
  Address3:    
  *Town:    
  County:    
  *Postcode:    
  Country:    
     
A4
*Your Email address
(Please use the same email as the one you registered with. We will send you an acknowledgement and a copy of your completed application form once you have submitted it.)

      
     
A5
*Telephone Number

        
A6
Mobile Number

        
A7
*National Insurance Number
(We only use your National Insurance number as a unique reference on our database.)

      
     
A8
*Date of Birth

      
A9
*Marital status

      
A10
*Where did you hear about Clergy Support Trust?

      
A11
*Please indicate which best describes you (or the clergyperson in the household):

      
B1
*Please indicate which type of Health Grant you are applying for?
(Click on the orange question mark ? shown on the right, for a list of grant categories.)

     ?
B2
*Please tell us about your current health situation and the reasons why you are applying? Where applicable, please provide details of any costs involved.
(Please supply any documentation that may support your application e.g. quotes/receipt of health related state benefits/medical assessment reports or occupational therapist assessments etc. If you are serving clergy please supply a copy of your latest stipend/salary slip as confirmation of your clergy status.)

      
B3
*In relation to your request for a health grant, have you visited your GP in the first instance and were you given a referral letter? Have you explored availability through the NHS/Irish HSE or other social care/statutory services? How long is the waiting list? Please give details:

      
B4
*Have you approached your Diocese, or any other charitable organisations, in relation to what you are applying for?

      
B5
If 'Yes', to the above question, please provide details of any amounts secured or applied for, who you've approached and when you're likely to hear.

      
B6
*Is this your first time applying to Clergy Support Trust?
(formerly Sons & Friends of the Clergy).

      
C1
*Are you (or your spouse/civil partner) a serving or retired member of the Anglican Clergy?
(E.g. For serving clergy - Beneficed, Licensed or PTO.)

      
C2
Ordination Date

     ?
     
C3
Current/Former Diocese

      
C4
Current/Former Parish

      
C5
Current/Former position
(e.g. vicar, priest in charge, assistant curate, chaplain etc.)

      
     
C6
Please tell us if you are (or your spouse/civil partner is); stipendiary/self-supporting/salaried/PTO/other?

      
C7
If you are retired please tell us your retirement date.

      
C8
Did you retire due to ill-health?

      
C9
If you retired due to ill-health, please feel free to provide further details about your retirement?

      
C10
*Are you (or anyone in your household) currently prohibited by a Clergy Discipline Measure (CDM) or other sanction from carrying out your Ministry?

     ?
     
D1
*Are you divorced/separated from or the widow(er) of a serving/retired member of the Anglican Clergy?

      
D2
*Please provide the full name of your former/deceased spouse/civil partner.

      
D3
*Please provide the date of birth of your former/deceased spouse/civil partner (dd/mm/yyyy).

      
E1
*Do you have any children?

      
E2
*Please tell us how many dependent children are living in your household.

Aged 0 - 1 Aged 2 - 4 Aged 5 - 10 Aged 11 - 18
   
E3

Do you share your home with anyone else? E.g. adults who are dependent on you (e.g. adult children/other family members in receipt of disability benefits) or lodger/s? Please give details.

(Please state the relationship do not include spouse/civil partners, dependent children).


      
F1
Please give details of any state benefits received.
(Please enter the annual amounts of any state benefits received. Only enter numbers in these fields, please do not enter commas or any other characters.)

State Benefits Self £ Spouse/Partner £
Child Benefit
Universal Credit
Working Tax Credit
Child Tax Credit
Council Tax Support
Housing Benefit
Jobseeker's Allowance
Employment & Support Allowance
PIP/Disability Living Allowance
Attendance Allowance
Carer's Allowance
Any other State Benefit
  ?
G1
*Do you live in a parochial house or other tied housing (as your main residence)?

      
     
     
     
H1
*Do you or your spouse/partner own any other property, other than your main residence (regardless of the use or the amount of outstanding mortgage)?

      
     
I1
Please complete with details of all current assets for yourself and your spouse/partner.
(Only enter numbers in these fields, please do not enter commas or any other characters.)

Details Self £ Spouse/Partner £
Current account balance
Bank/Building Society savings
ISA
Stocks & Shares
Other investments
   
J1
Please complete the table:

Lender Purpose Amount Outstanding £ Monthly repayments being made £
  ?
     
J2
If you are concerned about your debts, would you like us to signpost you for some debt advice/help?

     ?
J3
Are you currently paying into a Debt Management Plan?

      
     
J4
If 'Yes', please provide us with some further information.

      
K1
Please upload your supporting documents.

        
K2
Please upload your supporting documents.

        
K3
Please upload your supporting documents.

        
K4
Please upload your supporting documents.

        
K5
Please upload your supporting documents.

        
L1
Bank/Building Society name

      
L2
Account holder's name e.g. Mr John Smith

      
L3
Account Number

      
L4
Sort Code
(Please enter a six digit Sort Code with no spaces or separating characters.)

      
M1
We ask this to ensure that any discretionary gift that the charity may award you does not affect your entitlement to means-tested state benefits.

      
N1
*

Please tick here:


      
O1
*

I confirm that I have fully and correctly completed this form to the best of my ability and belief and given all relevant information to enable my application to be considered. I am content to provide corroborating evidence if requested. I acknowledge that Clergy Support Trust has a zero-tolerance policy towards fraud and expects that all information provided by applicants (or provided on their behalf) is given in good faith, with due care and attention, and is accurate to the best of the applicant's knowledge. This applies to information given by any means of communication. I further acknowledge that Clergy Support Trust will take appropriate action if any information provided is found to be false.


      
O2
If you have not uploaded your documents, please tick to confirm that you will be sending all of your supporting documents, relating to your income, by post, within 10 days of submitting your application eg: latest Stipend/Pension slip, HMRC Child Tax Credit Award Letter (all 6 pages) must be for the current year, PIP, DLA, Carer's Allowance, Council Tax & Housing Benefit Award letters, any other income documents.

      
O3
*I would like to receive updates from Clergy Support Trust.

      
O4
Please provide any feedback that you have regarding the application process.

      
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