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Annual Review
Annual Review Form 2023
Step
1
of
9
– If you are already receiving assistance from The Gurney Fund, please submit the annual review form electronically.
11%
Please confirm that you are receiving/have received assistance from Police Children's Fund.
*
I am in receipt of / have received assistance from Police Children’s Fund and
I consent to the information I provide being held and processed by Police Children’s Fund as necessary for the administration of this and any other application I make to the Fund. I consent to (a) the fact that I have applied and (b) details of any grant(s) made as a result of my application(s) being shared with the contributing force.
Applicant's Name
*
Your name
Address
*
Street Address
Address Line 2
City
Post Code
Email
*
Telephone No
*
Is this application the result of a death or retirement?
*
Death
Retirement
Force at time of officer's death
*
Force at time of officer's retirement
*
Cause was
*
On Duty
Off Duty
Date of officer's death
*
DD slash MM slash YYYY
Date of officer's retirement
*
DD slash MM slash YYYY
Details of any grants. awards or compensation received
Bereavement Allowance
Pension Commutation
Death in Service Benefit
Police Federation Award
Police Care UK
Compensation Awarded
Life Assurance Payment
How has this money been used?
Please enter details below
Dependant children's full names
Child's Details
First name
Last name
Date of Birth
Age
Adults
*
Children
*
Total residents at this address
MONTHLY INCOME – Please give Net figures
Monthly earnings (self)
Monthly earnings (spouse/partner/other family members)
Police Pension (self)
Police Pension (children)
State Pension
Occupational Pension
Bereavement Allowance (52 weeks) / Widowed Parent's Allowance
Police Charities: Police Care UK, COPS, Force Welfare/Benevolent Fund etc
The Police Children's Fund (Gurney Fund)
Maintenance Payments (including CSA)
Other Income
(specify) e.g. property rental – UK and abroad
Other income source
Please provide details
BENEFITS & CREDITS
Please give monthly figures
Child Benefit
total per month
Universal Credit
total per month
Please itemise Universal Credit (Job Seeker’s, Child Tax Credit, Housing Benefit etc)
Other Benefits & Credits
total per month
Please itemise (Disability Living Allowance, Council Tax Benefit, Carer’s Allowance etc)
Please give details of funds held in savings and investments at present
Total income generated from savings and investments (calculated on a monthly basis)
total per month
Other Income
total per month
Other income details
Total Monthly Income and Benefits
Monthly Expenditure
Mortgage / Rent
Council Rates
Property Maintenance
Water Rates
Gas / Oil / Solid Fuel
Electricity
Life Assurance
Insurance (buildings/contents)
CSA / Maintenance Payments
Food "housekeeping"
including newspapers/toiletries/laundry etc.
Clothing
Telephone Landline
Telephone Mobile
Internet & TV Packages
School Expenses
e.g. uniform, meals and trips
Private School Fees
Further / Higher / Adult Education Fees
Television Licence
Vehicle Breakdown Cover
Vehicle Fuel
Vehicle Insurance & Tax
Vehicle MOT and Servicing
Number of Vehicles
Children's Pocket Money
Pet Expenses
Child Care
Hairdressing
Regular Subscriptions
Hobbies / Leisure / Sport
Public Transport
Medical / Dental / Glasses/ Lenses
Other Expenses
Other Expenses Details
please provide a break down of your other expenses above
Total Monthly Expenditure
ADDITIONAL MONTHLY CREDIT COMMITMENTS
e.g. Hire Purchase Agreements, Loans – car, bank, etc). Do not include items listed under “Monthly Expenditure”
Purchase Details
Details
Amount per month
Date of final payment
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