NABS Assessment Form - NABS
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NABS Assessment Form

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Name value is required

Address value is required

Telephone number value is required

Email Address value is required

Date of birth value is required

National Insurance number value is required

Relationship status value is required

Employment status value is required

Please give the following details for everyone in your household: name, date of birth, relationship to you, contribution to household expenses value is required

Type of property you live in e.g. house, flat, bed-sit etc. value is required

Number of bedrooms value is required

Is your property rented? value is required

Current value of your property value is required

Type of mortgage value is required

Outstanding mortgage amount value is required

Please tell us about your circumstances. This could include any changes to your living circumstances, health or employment status since we last assessed you value is required

If you have made, or are making an application to any other charity or organisation please provide details here, including dates and types of support received/applied for value is required

Financial Details – please enter your weekly income in the spaces provided below; if you prefer to use monthly figures please indicate this by placing M next to the amount.

Weekly income e.g. salary, Jobseekers Allowance, Employment Support Allowance, state pension, other pension etc. value is required

Partner's income value is required

Contribution from family/friends value is required

Child tax credit value is required

Working tax credit value is required

Guaranteed Pension Credit value is required

Saving Pension Credit value is required

Council Tax Reduction value is required

Housing benefit value is required

Mortgage assistance value is required

Disability Living Allowance/Personal Independence Payment value is required

Attendance Allowance value is required

Child Benefit value is required

Carers Allowance value is required

Other (please specify) value is required

Grants from other charities value is required

Total weekly income including all of the above value is required

Financial assets e.g. savings account, ISA, bonds etc. value is required

Financial Details – please enter your weekly expenses in the spaces provided below; if you prefer to use monthly figures please indicate this by placing M next to the amount.

Rent or mortgage value is required

Ground rent value is required

Building and contents insurance value is required

Council tax value is required

Water value is required

Electricity/gas/oil value is required

Other (please specify) value is required

Food value is required

Telephone bill value is required

Travel/car value is required

Home help value is required

Job search expenses value is required

Other (please specify) value is required

Total weekly expenses including all of the above value is required

Debt repayment details – please enter your weekly debt repayment expenses in the spaces provided below; if you prefer to use monthly figures please indicate this by placing M next to the amount.

Credit card(s) value is required

Loans value is required

Other (please specify) value is required

Total weekly debt repayment expenses including all of the above value is required

Please provide us with your bank details below, including: bank name, bank address, sort code, account number, account holder name. This information is supplied on the understanding that it will only be used to credit your account with any agreed grants from NABS. value is required

I hereby declare that all questions contained in this form have been fully and truthfully answered to the best of my ability and that the details of income expenditure and capital are correct.

I authorise NABS to approach my bank, accountant, Department of Work and Pensions or Local Authority position for the purpose of verifying my financial position and other Charities on my behalf, as needed.

I understand that the details disclosed on this form by me will be held by NABS under the terms of the Data Protection Act 1998 for the purpose of assessing and reviewing any support from NABS.  This information will not be disclosed to other parties without my permission.

Signature: I agree that by writing my given name in full in the box below and submitting this form, that I am electronically signing this application value is required

Spouse/partner signature if applicable: I agree that by writing my given name in full in the box below and submitting this form, that I am electronically signing this application value is required

We require the following documents to verify your application. Please send originals, not photocopies; your documents will be returned to you as quickly as possible. If you can’t provide any of the relevant documents on the list below, please call us for further advice: 020 7290 7070.

Your most recent payslip file is required

Your most recent payslip file is too large (must be less than 3MB)

Your most recent pension statement file is required

Your most recent pension statement file is too large (must be less than 3MB)

Your partner's most recent payslip file is required

Your partner's most recent payslip file is too large (must be less than 3MB)

Your partner's most recent pension statement file is required

Your partner's most recent pension statement file is too large (must be less than 3MB)

Your DWP notification of all benefits plus notification of any Tax Credits file is required

Your DWP notification of all benefits plus notification of any Tax Credits file is too large (must be less than 3MB)

Your partner's DWP notification of all benefits plus notification of any Tax Credits file is required

Your partner's DWP notification of all benefits plus notification of any Tax Credits file is too large (must be less than 3MB)

Mortgage statement/copy of rent tenancy file is required

Mortgage statement/copy of rent tenancy file is too large (must be less than 3MB)

Your bank/building society/Post Office statements from the last 3 months file is required

Your bank/building society/Post Office statements from the last 3 months file is too large (must be less than 3MB)

Your partner's bank/building society/Post Office statements from the last 3 months file is required

Your partner's bank/building society/Post Office statements from the last 3 months file is too large (must be less than 3MB)

Statements relating to your financial assets e.g. saving accounts/ISA/Bonds file is required

Statements relating to your financial assets e.g. saving accounts/ISA/Bonds file is too large (must be less than 3MB)

Statements relating to your partner's financial assets e.g. saving accounts/ISA/Bonds file is required

Statements relating to your partner's financial assets e.g. saving accounts/ISA/Bonds file is too large (must be less than 3MB)

Statements of debt e.g. loans, credit cards file is required

Statements of debt e.g. loans, credit cards file is too large (must be less than 3MB)

Statements of debt pertaining to your partner e.g. loans, credit cards file is required

Statements of debt pertaining to your partner e.g. loans, credit cards file is too large (must be less than 3MB)

Any paperwork relevant to the areas you need help with from NABS file is required

Any paperwork relevant to the areas you need help with from NABS file is too large (must be less than 3MB)

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