Provincial Office 8 The Esplanade, Sunderland, SR2 7BH Tel: 0191 567 5365 E-mail: benevolence@pgldurham.org Web: www.durhamfreemasons.org
The Most Antient and Honourable Fraternity of Free and Accepted Masons of England
Chairman John David Watts
The Benevolent Committee of the Province of Durham
Vice Chairman Simon Craig Steele
Durham Benevolence Ltd Registered Charity No: 279313
Treasurer Edwin John Jeffrey
Secretary Tom F Gittins
APPLICATION FOR SHORT TERM EMERGENCY GRANT LODGE ………….…..……….…….
NAME
...................................................................................
ADDRESS
............................................................................................................................................... ...............................................................................................................................................
PARTICULARS OF PRESENT FINANCIAL CIRCUMSTANCES INCOME
£
p
Per Wk/Mth/Yr
1. Retirement Pension
.....................
........................
2. Supplementary Payments (Benefits)
……………...
..……….………
3. Any other Pension (Where from)
.....................
........................
4. Any Investments (Income & Investments)
.....................
........................
5. Details of all Capital
.....................
........................
6. Interest at Bank/Post Office/Savings Bank, etc.
.....................
........................
7. Any other Income
.....................
........................
1. Any Mortgage Payment
....................
.............................
2. Rent
....................
..............................
3. Council Tax
....................
..............................
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
................................................................................
Witnessed ..................................................................................
(Applicant)
Date ………………………
(VV)
Date ………………………
OFFICE USE ONLY Agreed
Yes/No
Signed………..………………………………….……..
Date ……………..………….
Reason if Declined ………………………………………………………………………………………………………. Date Cheque Issued
…….…………………................
Cheque No …………………….......……..........