Annual Review Form 2022 Step 1 of 10 - If you are already receiving assistance from The Gurney Fund, please submit the annual review form electronically. 10% Please confirm that you are receiving/have received assistance from The Gurney Fund.* I am in receipt of / have received assistance from The Gurney Fund and I consent to the information I provide being held and processed by The Gurney Fund as necessary for the administration of this and any other application I make to the Fund. I consent to (a) the fact that I have applied and (b) details of any grant(s) made as a result of my application(s) being shared with a Subscribing Force. Applicant's Name* Your nameAddress* Street Address Address Line 2 City Post Code Email* Telephone No*Is this application the result of a death or retirement?* Death Retirement Force at time of officer's death* Force at time of officer's retirement* Cause was* On Duty Off Duty Date of officer's death* DD slash MM slash YYYY Date of officer's retirement* DD slash MM slash YYYY Details of any grants. awards or compensation receivedBereavement AllowancePension CommutationDeath in Service BenefitPolice Federation AwardPolice Care UKCompensation AwardedLife Assurance Payment How has this money been used?Please enter details below Dependant children's full namesChild's DetailsFirst nameLast nameDate of BirthAge Adults*Children*Total residents at this address MONTHLY INCOME - Please give Net figuresMonthly earnings (self)Monthly earnings (spouse/partner/other family members)Police Pension (self)Police Pension (children)State PensionOccupational PensionBereavement Allowance (52 weeks) / Widowed Parent's AllowancePolice Charities: Police Care UK, COPS, Force Welfare/Benevolent Fund etcThe Gurney FundMaintenance Payments (including CSA)Investment Incomei.e. amount received each month not the amount investedOther Income(specify) e.g. property rental - UK and abroadOther income sourcePlease provide details BENEFITS & CREDITSPlease give monthly figuresChild Benefittotal per monthUniversal Credittotal per monthPlease itemise Universal Credit (Job Seeker’s, Child Tax Credit, Housing Benefit etc)Other Benefits & Creditstotal per monthPlease itemise (Disability Living Allowance, Council Tax Benefit, Carer’s Allowance etc)Other Incometotal per monthOther income detailsTotal Monthly Income and Benefits Monthly ExpenditureMortgage / RentCouncil RatesProperty MaintenanceWater RatesGas / Oil / Solid FuelElectricityLife AssuranceInsurance (buildings/contents)CSA / Maintenance PaymentsFood "housekeeping"including newspapers/toiletries/laundry etc.ClothingTelephone LandlineTelephone MobileInternet & TV PackagesSchool Expensese.g. uniform, meals and tripsPrivate School FeesFurther / Higher / Adult Education FeesTelevision LicenceVehicle Breakdown CoverVehicle FuelVehicle Insurance & TaxVehicle MOT and ServicingNumber of VehiclesChildren's Pocket MoneyPet ExpensesChild CareHairdressingRegular SubscriptionsHobbies / Leisure / SportPublic TransportMedical / Dental / Glasses/ LensesOther ExpensesOther Expenses Detailsplease provide a break down of your other expenses aboveTotal Monthly Expenditure ADDITIONAL MONTHLY CREDIT COMMITMENTSe.g. Hire Purchase Agreements, Loans - car, bank, etc). Do not include items listed under "Monthly Expenditure"Purchase DetailsDetailsAmount per monthDate of final payment And finally, if you wish to apply for assistance with educational expenditure, please attach receipts.Please upload scans Drop files here or Select files Max. file size: 128 MB, Max. files: 20. Δ
