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FIFESHIRE FOUNDATION APPLICATION
The Fifeshire Foundation is a Charitable Trust that provides grants to people living in Nelson Tasman who are in hardship and/or domestic crisis. We can help with personal needs, household costs, critical bills, health costs, and children's costs. We can also offer interest-free loans for $500 -$1,000.
THINGS WE CAN GRANT ASSISTANCE FOR:
Clothing • Shoes • Glasses • Firewood • Baby gear • Food (Countdown vouchers) • Furniture • Rent • Bond • Power • GP • Bills • Cell phone (for safety reasons) • School stationery • School supplies • School camps • School uniforms • Holiday programmes • Bedding and linens • Counselling • Respite care • Disability • Health aids • Driving lessons • Driving licence fees • Refrigerators • Washing machine • Surgery (details needed) • Dental work (simple, such as extractions for pain relief or fillings)
THINGS WE CAN'T HELP WITH:
Car Repairs: We only pay vehicle costs such as registration and warrant when these are the only costs required to move forward. We don’t normally pay for vehicle repairs but may consider this under exceptional circumstances, such as when a legal requirement or to start work or study.
Advanced dental work: We cannot help with dental surgery and specialists’ costs. Dental decisions are made on a case by case basis. Public hospital treatment is not possible.
Organisations’ ongoing costs: We cannot help with organisations’ ongoing rent, power and wage costs.
Applications are due by the 25th of each month.
Trustees meet on the second Friday of each month; applications are considered the month after they are submitted.
We will contact you about the outcome of your application about one week after the Trustees’ meeting.
Our Trustees meet monthly to allocate grants.
• We never give out cash. Instead, we pay bills or purchase items on people’s behalf.
• We consider applications based on evidence of need, and people’s efforts to address a situation.
• Applicants must include a budget worksheet signed by a budget adviser. If this can’t be done, say why and complete the budget part of the application.
• Your application must include quotes, bills, payment information or invoices for your requested grant.
• Please be realistic in the amount you apply for.
• Details about Work and Income support are required in the application.
• Signatures are required of two referees who have seen the completed application.
We cannot consider incomplete applications and will return these to the contact person.
Your completed application will only be viewed by the Fifeshire Foundation Trustees and Manager. The Trustees and Manager will keep confidential all information regarding applicants and their applications that is transferred verbally, in written and electronic form.
Where further information about the application is required, this will only be with the consent of the applicant, and for the purposes of considering the application.
Please contact Fifeshire Foundation on 027 334 3374 if you have any questions about completing this form.
PLEASE MAKE SURE YOU CAN COMPLETE THIS APPLICATION AT ONE TIME. YOU CANNOT SAVE THIS APPLICATION TO RETURN TO AT A LATER TIME.
Date of application
Group
Applicants 2019-2020
CONSENT
CONSENT Please tick as consent for us to contact any of the support people, contact person, health professionals, support workers or any other parties in relation to your application.
We may only need to do this in order to better understand your situation and how this meets the application criteria. Please note, we may not be able proceed with your application unless consent is granted. In this case we will contact you to discuss.
INDIVIDUAL APPLICANT
Applicant's name
*
First name
Last name
Applicant's address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Post Code examples: Nelson 7010, PO Box Nelson 7040, Stoke 7011, Richmond 7020, PO Box Richmond 7050, Motueka 7120, PO Box Motueka 7143, Tasman 7173, Takaka 7110
Applicant's phone number
Applicant's alternate phone number, if applicable
Application email address - this is the email address that all correspondence will be sent to.
Are you applying for dental work?
No
Yes
Are you applying for surgery?
No
Yes
Are you applying for an interest free loan?
No
Yes
Have you or a member of your household or family applied in the past. Type Yes or No
Total number of people (including yourself) for whom you are financially responsible
*
Number of adults 18+ in the household (including yourself if you are 18+)
Number of children 17 and under (17 and under) in the household (including yourself if your are 17 or under)
Please ensure you have exhausted all other options for assistance including Work & Income entitlements. Please see separate form (Step Three) for verification from Work & Income.
Work & Income entitlement Summary
Click here
Please contact Fifeshire Foundation on 027 334 3374 if you have any questions about completing this form.
If you are applying for someone else do you have their permission?
YES
NO
CONTACT PERSON FOR APPLICANT - ONLY COMPLETE THIS SECTION IF APPLICABLE (see explanation below)
A contact person is someone we can contact regarding all matters in this application if we are unable to get in touch with the applicant, or if the applicant has no means of being contacted (such as no phone, or email).
Contact person's name
First name
Last name
Contact person's email address
Contact person's phone number
Contact person's relationship or organisation
+ Add another
- Remove
WHAT IS THIS APPLICATION FOR?
List what is being applied for, including the itemised costs. Please note quotes and/or payment details will be required
*
Total cost of application
Please put the applicant name on every page and forward to us your supporting documents, in one of the following ways:
Take a photo and text it to 027 334 3374
OR Take a photo and email it to info@fifeshirefoundation.co.nz
OR Scan and email it to info@fifeshirefoundation.co.nz
OR post it to:
Fifeshire Foundation
PO Box 907
Nelson 7040
OR drop it in to us at:
Fifeshire House
326 Trafalgar Square
Nelson (next to Jens Hansen Jewellers).
Please contact Fifeshire Foundation on 027 334 3374 if you have any questions about completing this form.
APPLICATION SUPPORT PEOPLE (TWO REQUIRED)
At least two people are required to support this application, e.g. budget adviser, minister, Work & Income New Zealand, support or social worker, doctor or nurse, minister, employer, lawyer, teacher or principal. NOT family members or friends.
If you are applying for Charity Surgery, please ensure your GP or doctor is one of your support people, and that they also complete a Nelson Tasman Charity Surgery Referral and Declaration form.
ALTERNATIVELY you may also email, post, photograph & text, or drop in a supporting letter from two supporters, again, NOT family members or friends.
You may have as many supporters as you like, as long as there are at least two.
If your support people are not able to use the APPLICATION SUPPORT PEOPLE form link below, they can send a letter by email, post, photograph & text, or drop in at Fifeshire Foundation. NOT family members or friends.
APPLICATION SUPPORT PERSON
Click here
Please note: You need to submit this entire application and then ask your support people to fill in the APPLICATION SUPPORT PERSON form. They will need your application number which is emailed to you after you have submitted your application.
TO COMPLETE YOUR APPLICATION, PLEASE PROVIDE A BUDGET SHEET SIGNED BY A BUDGET ADVISER
To support your application we require you to provide a completed budget from an approved agency such as Nelson Budget Services Ph 03 546 9021, Te Korowai Trust Stoke Ph: 03 547-5958, Te Piki Oranga (for TPO engaged clients) Wakatu and Richmond Ph 03 543 7016, Motueka Family Service Centre Ph 03 528 0234, Mohua Social Services Takaka Ph 03 525 9728. If you are not able to do this you will need to outline why not below.
Please include your application reference number (provided when you complete your application) name your budget sheet on every page and forward your budget sheet in one of the following ways:
Take a photo and text it to 027 334 3374
OR Take a photo and email it to info@fifeshirefoundation.co.nz
OR Scan and email it to info@fifeshirefoundation.co.nz
OR post it to:
Fifeshire Foundation
PO Box 907
Nelson 7040
OR drop it in to us at:
Fifeshire House
326 Trafalgar Square
Nelson (next to Jens Hansen Jewellers).
If your circumstances mean you are unable to provide a budget sheet signed by a budget adviser, please explain why and then complete the remainder of the application form below.
WEEKLY HOUSEHOLD INCOME AND EXPENSES
INCOME
Total weekly salary and wages and other earnings (EXCLUDING Work & Income support) from all members in the household
If no salary and wages and other earnings please enter $0
Total weekly Work & Income support from all members in the household, including any Family Tax Credits
If no Work & Income support please enter $0
TOTAL amount of all income
EXPENSES
Rent or Board
Mortgage
Food
Electricity, gas, water
Landline phone and internet
Mobile phone
Debts
Children costs
Clothing
Medical costs
Car expenses, fuel and transport
Insurance
Other expenses not listed above
Any comments regarding expenses
Total amount of all expenses
APPLICANT'S SITUATION REQUIRING GRANT
Please tell us about your application due to financial hardship or domestic or financial crisis. Please explain what has led to this situation, how your family is impacted, and how the grant will benefit your situation.
*
Acknowledgement of application. By ticking this box you are confirming you have given true and accurate information on this application. This is considered your application's digital signature. This is required for your application to be considered.
*
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