Your application for financial help If you can't complete the whole form right now, don't worry - you can save your progress and return later. Just use the link at the bottom of the page. Step 1 of 13 7% Section 1: Your detailsYour name* Title First name Middle name(s) Last name Email address*Please ensure you enter a working email address so we can contact you. Postal address* Address line 1 Address line 2 Town/City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Home phone number Mobile phone number* Date of birth*dd/mm/yyyy Marital status*If more than one option applies, please choose the one that best describes your current situation Married Living with Partner Co-habiting Single Separated Divorced Widowed Partner/spouse's name (if applicable)* Title First name Middle name(s) Last name Partner/spouse's date of birth (if applicable)*dd/mm/yyyy Partner/spouse's occupation (if applicable)* How did you hear about the RMBF?* Please provide details of any communication requirements you have due to medical reasons, e.g. large print letters Section 2: Your details (cont.)Please select one of the following:* I am a doctor I am/was the dependant of a doctor GMC Number* Specialty* Date you last worked (if you are not currently working)dd/mm/yyyy Name of the doctor you are/were dependent on* Title First name Middle name(s) Last name Their GMC Number* Your relationship to them* If they have died, please provide their date of death*dd/mm/yyyy Section 3: Other people who live with youIncluding part-time (e.g. studying at university)Please add details below*Add extra rows if applicable by clicking the "plus" button. If there are no other people living with you, please write "None" in the first box.NameDate of birth (dd/mm/yyyy)Relationship to you Section 4: Household incomeIt’s very important that you complete the tables below in as much detail as possible. Please ensure you select the correct frequency from each drop-down list, and provide exact figures. For any types of income that you don’t receive, please write "None" in the Amount column. For any types of income that you’ve applied for, but not yet received, please write "Applied" in the Amount column. We will ask for documents to support this information at a later stage, once eligibility has been confirmed.Your income from employmentNet salary* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Sick pay* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Your partner/spouse's income from employmentIf applicableNet salary* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Sick pay* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Your pensionsIf currently in receipt of pension incomeOccupational pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Private pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) State pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Pension credit* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Your partner/spouse's pensionsIf applicableOccupational pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Private pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) State pension* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Pension credit* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Your state benefitsUniversal Credit* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Housing Benefit* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Support for Mortgage Interest* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Council Tax Reduction / Support* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Employment and Support Allowance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) DLA / PIP (Care / Daily Living Component)* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) DLA / PIP (Mobility Component)* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Attendance Allowance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Carer's Allowance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Child Benefit* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Your partner/spouse's state benefits*Please specify the type, and add extra rows if applicable by clicking the "plus" button. If they recieve no state benefits, please write "None" in the first box.DescriptionFrequencyAmount (£) Child Maintenance income* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Any other income*Please specify the type, and add extra rows if applicable by clicking the "plus" button. If you have no other sources of income, please write "None" in the first box.DescriptionFrequencyAmount (£) Your partner/spouse's other income*Please specify the type, and add extra rows if applicable by clicking the "plus" button. If they have no other sources of income, please write "None" in the first box.DescriptionFrequencyAmount (£) Section 5: ExpenditurePlease fill in the table below. If you are in a couple/interdependent relationship, please enter the full amount for each cost. If you live in a house share or are currently living with parents, please only enter your share or contribution towards each cost. Other essential costs (food, travel expenses, internet, etc.) will be taken into account according to the number of people in your household.Mortgage* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Rent* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Ground Rent* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Service Charge* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Council Tax*Full amount before any reductions Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Electricity* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Gas* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Water* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Buildings and Contents Insurance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Mortgage Protection Insurance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Income Protection Insurance* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Child Care* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Care Costs* Frequency WeeklyFortnightly4-weeklyMonthlyAnnually Amount (£) Professional Subscriptions*Please specify the type, and add extra rows if applicable by clicking the "plus" button. If you are not paying for any professional subscriptions, please write "None" in the first box.DescriptionFrequencyAmount (£) Other expenditurePlease specify the type, and add extra rows if applicable by clicking the "plus" button.DescriptionFrequencyAmount (£) Section 6: Bank accounts, savings and capitalPlease provide full details of all current accounts, savings accounts, ISAs, trust funds, stocks, shares, bonds and investments that you (and your partner, if applicable) have. You will need to provide statements for all bank accounts (including savings accounts) covering the past three months. It’s a good idea to request or download these statements while you are verifying the balance information below. Please continue on a separate sheet if needed.Bank accounts*Add extra rows if applicable by clicking the "plus" button.Account name and typeCurrent balance (£) Section 7: DebtsPlease give details of all unsecured loans, hire purchase, credit cards and any other debts that you (and your partner, if applicable) have. This information will be used should your application be referred to our Money Adviser.Debts*Add extra rows if applicable by clicking the "plus" button. If you don't owe any debts, please write "None" in the first box.CreditorCurrent balance (£)Minimum monthly repayment (£) Have you approached any of your creditors to renegotiate your contractual monthly payments?* Yes No N/A If yes, please provide details*Have you received any money advice / debt advice?* Yes No If yes, from whom?* Section 8: Housing detailsPlease select one of the following to describe where you are currently living:* Mortgaged / owned outright Rented from a private landlord Rented from a Housing Association / Local Authority Living with a relative Refuge For home ownersThis section is only for those who own a home (whether mortgaged or owned outright). If this does not apply, please leave this blank.When did you purchase your home?* Month Year What is the current value of your home? (£)* Do you have a mortgage?* Yes No If yes, what is the current balance? (£)* Do you have any loans secured on your home (other than the mortgage noted above)?* Yes No If yes, please provide details*Do you own any other properties?* Yes No If yes, please provide details* Section 9: Cars and other vehiclesCars and other vehicles*Add extra rows if applicable by clicking the "plus" button. If you don't own any vehicles, please write "None" in the first box.Type of vehicleMake and modelYearCurrent monthly repayment (if applicable) (£) Section 10: Other charitable assistanceAre you currently receiving assistance from any other charity, organisation, or fundraising page (e.g. GoFundMe)?* Yes No If yes, please provide details*Have you applied for assistance from any other charity or organisation, or set up a fundraising page (e.g. GoFundMe)?* Yes No If yes, please provide details* Section 11: Personal statementPlease provide details of the difficulties you are facing, what caused the difficulties, and any other information that will help us understand your situation. Please ensure that you include details of any expected changes to your income especially where it differs from what you have entered on the application form as your current income. You can either upload this as a document, or you can type/paste your letter into the box below. You don't need to do both.Upload personal statement as a separate documentMax. file size: 64 MB.Type/paste personal statement Section 12: Agreements and declarationsMain agreementI agree and understand that it is a condition of any award that I receive that the RMBF can liaise with other charities I have applied to and, if requested, may provide such charities with details of my personal and financial situation. I understand that such information will be treated in accordance with the Confidentiality Policies adopted by each charity. I declare that I have made a full and accurate statement of my financial circumstances and will notify the RMBF immediately when my circumstances change during the application process and / or after I have been notified of any grant that may be awarded. I understand that any false, misleading or undisclosed information will result in the termination of any grant that may be awarded and that legal consequences may follow.Please tick the box below* I agree to the above declaration Your name* Your partner/spouse's name*If applicable Today's date*dd/mm/yyyy Data protection agreementIn order to process your application to the RMBF, we will need you to read and sign this statement, giving your consent that the information you provide is being held and used for the purposes below. The Data Protection Act 2018 obliges us to notify you that we shall be holding data on you and your family. We require the data on your application forms and any additional information we may request, in order to: process new/review applications for assistance identify the nature and duration of assistance that may be required enable the RMBF to maintain contact with applicants and beneficiaries administer and maintain Casework Department records ensure consistency and fairness when considering applications collect aggregated statistical data comply with our Equal Opportunities Policy The information may also be used to identify alternative sources of help, and we may share information with any other charities to which you might apply. The information you provide will be held securely and processed only for the purposes indicated.Please tick the box below* I have read and understand the above, and give my consent for information to be held and used for the purposes described. Your name* Your partner/spouse's name*If applicable Today's date*dd/mm/yyyy Equality monitoringThe RMBF are committed to equality and diversity. In order for us to understand who we are reaching, and to help us ensure we are providing inclusive services and support, we would be grateful if you would complete this form. It will be used only for monitoring purposes. All details are held in accordance with the Data Protection Act 2018.Sex* Male Female Prefer not to say Age* 16-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Prefer not to say I would describe my ethnic origin as:*Please choose the most accurate category. Further options will appear once you have selected. White Mixed/multiple ethnic groups Asian/Asian British Black/African/Carribean/Black British Other ethnic group Prefer not to say White* English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller Mixed/multiple ethnic groups* White and Black Carribean White and Black African White and Asian Asian/Asian British* Indian Pakistani Bangladeshi Chinese Black/African/Carribean/Black British* African Carribean Other ethnic group* Arab Do you consider yourself to be disabled within the meaning of the Equality Act 2010?* Yes No Prefer not to say Submit your application belowPress the button below to submit your application. After that, one of our Casework team will be in touch within 3 working days.
