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Please enter your MONTHLY income. If your income fluctuates please use an average worked out over the previous 3 months
Evidence of all income received must be supplie (eg. Last three payslips, copy of benefit books, letters of entitlement, etc.)
Please work out the total monthly expenditure for your household (if your expenditure fluctuates please use an average worked out over the previous 3 months)
Evidence of expenditure must be supplied for all items marked **
Please list the item(s) required
Quotations must be supplied. See Guidelines for details
I certify that all the information provided on this application form is true and accurate to the best of my knowledge and belief.
I authorise any representative of the consolidated charity of burton upon trent to make any enquiries from any third party for the purpose of processing my application for financial assistance.
I accept that personal data supplied on this form will be held on file. Some details may be checked with relevant organisations but none may be disclosed for any inappropriate purpose. I understand i have access to this information on request.