Financial hardship support application form

Please complete and submit the form below.

Surname

Forenames

Home Address

Contact Number

Email Address

Confirm Email Address

Postcode

D.O.B.

Police employment status (please tick):

Serving officer

Retired officer

Current police force (if retired, previous force)

Collar Number

Date joined police force

If applicant is not a Serving or Retired Officer, please state whether you are a Surviving Spouse, Partner or a Dependent (please tick):

Surviving Spouse

Partner

Dependent

Any previous applications for financial assistance? (please tick):

YesNo

Briefly outline your reason for request for financial assistance:

I can confirm I am a member of The Ben Fund

Personal information which you supply to us may be used in several different ways, for example: To make admission and clinical decisions; for audit and statistical analysis; for fraud prevention.

The Ben Fund is committed to protecting your privacy and security. Whenever you provide personal information, we will treat that information in accordance with UK Data Protection legislation. Further details can be found in our Privacy Policy which can be found on our website at: https://www.thebenfund.co.uk/privacy-policy.

I understand that all personal information on this form will be confidential to the professional and administrative staff of The Ben Fund and no personal information or clinical reports will be shared without my express consent unless required by law.

I agree to The Ben Fund contacting me using the details I have provided.

Date /