PRS Members' Fund - support & advice to PRS members
APPLICATION FOR ASSISTANCE / FINANCIAL STATEMENTPlease fill in this form, answering the questions by giving as much detail as you can. Please mark the boxes N/A if the question does not apply to you. Your application will be treated in the strictest confidence.NAME IN FULLDATE OF BIRTHADDRESSMARITAL STATUSSingleMarriedDivorcedSeparatedCo-habitingCivil PartnershipWidowedTEL No.No. OF CHILDREN UNDER 18 YEARSMOBILEPRS CAE / IPIEMAIL ADDRESS BANK DETAILS(where any grant should be paid, if awarded)How did you hear about the Fund?DETAILS OF INCOMEPlease give the figures in whichever frequency (i.e. weekly, 4-weekly, monthly, yearly) is accurate and most convenient to you. Some benefit amounts are for a 4-weekly not monthly period, so for clarity please ensure to mark each entry with the correct amount and frequency.Your IncomeIncome of Spouse / Partner living with you (if applicable)AmountFrequency AmountFrequencyEarnings (after tax):Housing Benefit:Council Tax Benefit:Employment & Support Allowance:Universal Credit:State Retirement/Widows Pension:Pension Credit:Occupational/Private Pension:Attendance Allowance:Carer’s Allowance:Incapacity Benefit:DLA/PIP – Care:DLA/PIP – Mobility:Used for car? Yes ? No ?Tax Credits (please state which):Other Benefits (please specify):Other Income (please specify):Other Royalty Income:(e.g. PPL, MCPS, Publishing, Record Companies; please state)PRS Royalties (previous year):If you wish, you can attach a P60 or Tax Return from the previous year as evidence – however this is not compulsory.DETAILS OF EXPENDITUREAs above, please give the figures in whichever frequency is most convenient to you; the total should be for your household – you, and those you share responsibility for costs with, i.e. partners and dependants, but not housemates.Expenditure for your householdAmountFrequency Total Rent Payable:Total Council Tax Payable:Mortgage Repayments:Service Charge:Electricity:Gas:Water Rates:Other Heating Fuel (e.g. oil, coal. Not Petrol):Car Insurance:Car Tax:Gardening Fees:Home Help / Care Needs:Insurance – Building / Contents:Insurance – Personal:Landline / Internet / TV Package:Mobile Phone:Credit Card Regular Repayments:Bank Loan Regular Repayments:Other Essential Household Expenses (please specify, e.g. personal care products, pet insurance):ASSETS, SAVINGS, DEBTSDo you own your home?Yes ? No ?If yes, please state the approximate market value:What is the value of the outstanding mortgage?Do you own, or have shared interest in, any other properties?Yes ? No ?SavingsYouYour partnerCurrent Account Balance:Savings Account Balance:Business Account Balance:Other Savings - Please Specify e.g. Another Current Account, Building Societies, Post Office Accounts, Premium Bonds, Investments (ISAs or similar):Debts or LoansIf you have a fixed or agreed repayment amount, please give that figure. If you have a variable repayment amount based on interest, please give the most recent figure / bill.If you need more space, please attach an extra sheet.Total Amount OwedRepayment AmountFrequencyRent or Mortgage Arrears:Council Tax Arrears:Service Charge Arrears:Gas or Electricity Arrears:Water Rates Arrears:Telephone Arrears:Friend or Relative:Catalogue:Bank Overdraft:Loan Balances:Credit Card Balances:Social Fund Loan Balances:Other (please specify):PERSONAL DETAILSOthers in your householdNameAge (if under 16)Relationship to youHealth IssuesPlease give details of illness or disability affecting you, and any members of your household. If you need more space, please use the ‘Further Information’ section below. Please note, we may ask for GP or Hospital letters to confirm.NameIllness or DisabilityDate diagnosedYour Employment HistoryPlease give details of any work undertaken in the past 5 years only. You can include details of activities in the music industry if you wish – a CV of your career can also be submitted.EmployerJob DescriptionDates of EmploymentYour Spouse / Partner’s Employment HistoryPlease give details of any work undertaken in the past 5 years only. EmployerJob DescriptionDates of EmploymentAre you a member of any other professional organisations or unions?NameDate Joined (if known)Association of Independent Music (AIM)Incorporated Society of Musicians (ISM)Musicians Union (MU)Royal Society of Musicians (RSM)Music Managers’ Forum (MMF)Ivors AcademyAssistance from other organisationsPlease give details of any other charities or organisations to whom applications have been made – either currently, or in the past 5 years. Name of CharityDate of ApplicationAssistance Given (if a grant, please state the amount applied for / awarded)Further InformationPlease use this space to provide additional information in support of your application. Continue on a separate sheet if necessary.Your WellbeingWe want to understand more about how things are for you right now, and we appreciate you taking the time to complete the following 4 questions:Thinking about your current situation, to what extent do you feel:Settled - By this we mean how stable you feel your life, work, housing or finances are and whether you feel your personal situation is in a good place, but please feel free to interpret in?a?way that is meaningful for you.?Please indicate on a scale of 1 to 10, with 1 being ‘not at all’ and 10 meaning ‘completely’ 1 ? 2 ? 3 ? 4 ? 5 ? 6 ? 7 ? 8 ? 9 ? 10 ?Healthy?-?this is about your physical or mental health; how you feel in yourself generallyPlease indicate on a scale of 1 to 10, with 1 being ‘not at all’ and 10 meaning ‘completely’ 1 ? 2 ? 3 ? 4 ? 5 ? 6 ? 7 ? 8 ? 9 ? 10 ?Confident and independent?- whether you feel you have control in your life and able to make decisions about what’s next, but please feel free to interpret in?a way that is meaningful for you.?Please indicate on a scale of 1 to 10, with 1 being ‘not at all’ and 10 meaning ‘completely’ 1 ? 2 ? 3 ? 4 ? 5 ? 6 ? 7 ? 8 ? 9 ? 10 ?Creative and collaborative?- Whether you have new/old?ways to engage with music and can work with others?to do so?(if appropriate), but please feel free to interpret in?a way that is meaningful for you.?Please indicate on a scale of 1 to 10, with 1 being ‘not at all’ and 10 meaning ‘completely’1 ? 2 ? 3 ? 4 ? 5 ? 6 ? 7 ? 8 ? 9 ? 10 ?MonitoringThe PRS Members’ Fund (PRSMF) is committed to ensuring fair and equitable treatment of all who apply for assistance, and in keeping with general principles of diversity and inclusion.We encourage all eligible songwriters and composers in need to apply, and to complete the details below, though you are under no obligation to do so. The information is used only for internal monitoring purposes, to identify any action needed to reach the wider songwriter and composer community.This part of the form will be treated in the strictest confidence. Whether or not you complete it will not affect your application for support in any way whatsoever.Ethnic Background – Please select the box that best describes your ethnic origin:White:British / English / Welsh / Scottish / Northern Irish ?Irish ?Gypsy or Irish Traveller ?Another White background ?Asian / Asian British:British ?Indian ?Pakistani ?Bangladeshi ?Chinese ?Arab ?Any other Asian background ?Black / African / Caribbean / Black British:British ?African ?Caribbean ?Any other Black / African / Caribbean background ?Mixed / Multiple Ethnic Groups:White and Black Caribbean ?White and Black African ?White and Asian ?Any other Mixed / Multiple Ethnic background ?If you prefer, you can describe your ethnicity using your own words:left241049left86035PRIVACY NOTICE – GENERAL DATA PROTECTION REGULATION (“GDPR”)The details and sensitive information you have provided in this application form will be kept strictly confidential. Please read the following carefully, and sign in the box below.I CONFIRM THAT:I give my consent to the PRS Members’ Fund to process my personal data and financial information, including personal data provided to and held by PRS for Music, for the purposes of considering and verifying my eligibility for assistance, processing applications for assistance from the Fund and/or assisting applicants to access other potential sources of assistance.The details I have given on this application form are to the best of my knowledge true and correct.The PRS Members’ Fund may approach and share my information with other agencies/charities on my behalf to provide funding, and/or to confirm any assistance already awarded.The PRS Members’ Fund may contact me by email, telephone or in writing regarding my application for assistance.I will keep the PRS Members’ Fund informed of any changes to my financial circumstances during the application process. I understand that any false or undisclosed information could result in the withdrawal of the application or any subsequent grant awarded.If my circumstances should improve for the better, or if any other organisation shall give me additional support, I will immediately inform the PRS Members’ Fund.The PRS Members’ Fund may contact me after the award of a grant to ascertain how the grant has assisted me.I may withdraw my consent for any or all of the above, at any time, by writing to the address below, or emailing the General Secretary at: fund@ For full details on our use of your personal data, please see our Privacy Policy at : Date:Print Name:PRS MEMBERS’ FUND2 Pancras Square, London N1C 4AGTel: 020 3741 4067Registered Charity No: 1181735fund@ ................
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