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Care Fees Funding Advice - Online Application Form

To begin the process of obtaining your personal Care Fee Funding Report please complete and submit this short application form.

Our care fees adviser will contact you to obtain the full details needed to enable us to assess your own personal situation and offer helpful advice that could assist you in making important decisions for the funding of care home fees, now or in the future.

Please be assured that all information is treated in the strictest confidence. Please note that you are not entering into any obligation - our help and advice is available to all regardless of means.

You can also download a copy of the full application form that you can print, complete and return to us freepost: Download Form (PDF - 60kb)

Advice Required
	To meet immediate or existing care costs
	Planning for future independence with long term care insurance
	I am the person requiring care
	I am enquiring on behalf of the person requiring care

Contact Details Correspondence will be sent to this address
	Title: *
	First Name: *
	Last Name: *
	Address: *

	City/Town: *
	County: *
	Post Code: *
	Telephone: *
	Email:

Applicant's Details (person needing care) (If different to person to whom correspondence needs to be addressed)
	What relation is the applicant to you?
	Title:
	First Name:
	Last Name:
	Self Funding Care
	State Funding Care

Financial Information (Please tick all that are relevant and your Care Fees Adviser will obtain the details from you) Sources of income
	State Pensions:
	Private Pensions:
	State Benefits/Allowances:
	Investment Income:
	Other Income:

Capital and Savings
	Property:
	Bank & Building Society Deposits
	National Savings:
	Peps/ISAs:
	Shares or other Investments:
	Other:

Care Information (where applicable)
Type and expected cost of care (per week)
	Nursing Home
	Residential Care Home
	Domiciliary Care
Legal Arrangements
	Is an Enduring Power of Attorney held?
Financial Objectives or Circumstances (Capital Protection, Other Dependants, Mortgages etc)

Important Information
Personal Data

I/we declare and agree with the statements below:

To enable NHFA Ltd to conform with the Data Protection Act 1998 I/we agree that NHFA may use the information I/we have supplied to recommend appropriate schemes and administer my/our application (should I/we decide to apply for a scheme).

Any personal information I/we provide will be treated as private and confidential, and held and processed, on computer or otherwise, by NHFA Ltd as a result of my application (whether or not it proceeds) or any subsequent agreement.

NHFA Ltd may analyse the information they hold about me/us to help them improve their service to me/us, to monitor their business and for market research so they may identify any products or services which may be of interest to me/us.

From time to time, NHFA Ltd, its associated companies and carefully selected third parties may then contact me by letter, telephone, email or other appropriate means with offers reflecting my preferences.

Only if I/we decide to proceed with a product will my personal information be disclosed to potential product providers and their agents or to any person in circumstances where the disclosure is required by law.

I/we can obtain (on payment of a small fee) a copy of the information held by NHFA Ltd about me/us under the Data Protection Act 1998.

I/we declare that the statements and particulars given in this application are, to the best of my knowledge and belief, true and complete.

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