The Most Antient and Honourable Fraternity of Free and Accepted Masons of England
Provincial Office 8 The Esplanade, Sunderland, SR2 7BH Tel: 0191 567 5365 E-mail: benevolence@durhamfreemasons.org Web: www.durhamfreemasons.org
Chairman John David Watts
The Benevolent Committee of the Province of Durham
Vice Chairman Michael Stuart Shaw
Durham Benevolence Ltd Registered Charity No: 279313
Treasurer Stephen A Willis
Secretary Tom F Gittins
APPLICATION FOR SHORT TERM EMERGENCY GRANT NAME
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LODGE ………….…..……….…….
ADDRESS
............................................................................................................................................... ............................................................................................................................................... PARTICULARS OF PRESENT FINANCIAL CIRCUMSTANCES
INCOME
£
p
Per Wk/Mth/Yr
1. Retirement Pension
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2. Supplementary Payments (Benefits)
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..……….………
3. Any other Pension (Where from)
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4. Any Investments (Income & Investments)
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5. Details of all Capital
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6. Interest at Bank/Post Office/Savings Bank, etc.
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7. Any other Income
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1. Any Mortgage Payment
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.............................
2. Rent
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3. Council Tax
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EXPENSES
State if Petitioner or Late Husband is/was a Member of the Mark
YES/NO
Lodge No ………….................
Reason for Emergency Grant…………………………………………………….………………………………………….. ………………………………………………………………………………………………………………………….............. …………………………………………………………………………………………………………………………………… Amount of Lodge Grant ………………………… (If not why not) ……………..………………………………..………… I do hereby vouch for the truth and accuracy of the above information. Signed
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Witnessed ..................................................................................
(Applicant)
Date ………………………
(VV)
Date ………………………
OFFICE USE ONLY Agreed
Yes/No
Signed………..………………………………….……..
Date ……………..………….
Reason if Declined ………………………………………………………………………………………………………. Date Cheque Issued
…….…………………................
Cheque No …………………….......……..........