Application Form Application Form 2023 Step 1 of 11 9% Please confirm your eligibility before completing the form below.* I am eligible 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 Telephone No*Email* Force at time of officer's retirement* Date of officer's retirement* DD slash MM slash YYYY Cause was:* On Duty Off Duty 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)Other Income(specify) e.g. property rental - UK and abroadOther income sourcePlease provide details BENEFITS & CREDITSPlease give monthly figuresChild BenefitStatutory Sick PayDisability Working AllowanceDisability Living AllowanceAttendance AllowanceIndustrial Injuries Disablement BenefitSevere Disablement AllowanceCouncil Tax BenefitMaternity Allowance/Statutory Maternity PayReduced Earnings Allowance (only prior to Oct 1990)Carer's Allowance Universal Credit: Please ItemiseJob Seeker's AllowanceIncapacity Benefit / Employment Support AllowanceIncome SupportChild Tax CreditWorking Tax CreditsHousing BenefitOther IncomePlease specify in large box belowPlease give details of funds held in savings and investments at presentTotal income generated from savings and investments (calculated on a monthly basis)Please specify in large box belowTotal Monthly Income and Benefits Monthly ExpenditureMortgage / RentCouncil RatesProperty MaintenanceWater RatesGas / Oil / Solid FuelElectricityAssurance (life)e.g. endowment for mortgageInsurance (buildings)Insurance (contents)CSA / Maintenance PaymentsFood "housekeeping"including newspapers/toiletries/laundry etc.ClothingTelephone HomeTelephone MobileInternet / SatelliteSchool Expensese.g. meals and tripsPrivate School FeesFurther / Higher / Adult Education FeesTelevision LicenceVehicle Breakdown CoverVehicle FuelVehicle InsuranceVehicle Tax, MOT and MaintenanceNumber of VehiclesChildren's Pocket MoneyPet ExpensesChild Care / Baby SittingHairdressingRegular Subscriptionse.g. Union feesHobbies / Leisure / SportPublic Transporte.g. trains, school busMedical / Dental / Glasses/ LensesOther ExpensesPlease provide details belowOther Expenses Detailsplease provide a break down of your other expenses aboveTotal Monthly Expenditure ADDITIONAL MONTHLY CREDIT COMMITMENTSe.g. Hire Purchase Agreemenrs, Loans - car, bank, etc). Do not include items listed under "Monthly Expenditure"Purchase DetailsDetailsAmount per monthDate of final payment And finally please upload your documents below.HiddenA scan of your child's birth certificate.Max. file size: 128 MB.A scan of child's / children's birth certificate Drop files here or Select files Max. file size: 128 MB. Δ
