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A1
*Name

         
A2
*Date of Birth

      
A3
*Phone No.

        
A4
*Address
*Address1:      
  Address2:    
  Town:    
  County:    
  *Postcode:    
A5
*Email address
If the applicant does not have an email address please enter n/a

      
A6
*What is the individual's employment status?

      
A7
*Does the individual have any serious health conditions?
Please give details.

      
B1
*What does the individual need the grant for?
Please prioritise the items.
You cannot apply for items that are currently being requested through a Local Support Payment

     ?
B2
*Has the individual applied for a Local Support Payment?
Please enter 'yes' or 'no'

     ?
B3
What has been requested?

      
B4
When will the outcome be known?

      
B5
If a Local Support Payment has already been received, what was given?

      
C1
*Monthly Income
Please give details of all income relevant to the individual plus any income from their partner or members of their household, if applicable.

Source Individual Partner
Housing Benefit
State Retirement Pension
Private Pension
Pension Credit
Wages (net)
Universal Credit
Jobseeker's Allowance
Employment & Support Allowance
Income Support
Working Tax Credit
Child Tax Credit
Child Benefit
Carers/Attendance Allowance
Personal Independence Payment
   
C2
Please list income from any other members of the household

Member of Household Amount
   
C3
*Total Income

      
C4
*Any savings
Please list any savings for the individual or members of the household.

      
C5
*Monthly Expenditure
Please itemise all monthly expenditure for the individual.

Outgoings Amount
Rent
Council Tax
Water
Gas
Electricity
Phone/emergency call system
TV package i.e. Sky, BT/Broadband
Home care/help
Food, household items
Insurances
Credit cards
Store cards
Loans
Other/debt repayments
   
C6
*Total Expenditure

      
D1
*Name

         
D2
*Position

      
D3
*Organisation

      
D4
*Address
Address1:      
  Address2:    
  Address3:    
  Town:    
  County:    
  Postcode:    
D5
*Phone

        
D6
*Email

      
D7
*Name of Bank
Do not put N/A

     ?
D8
*Account Name
Do not put N/A

     ?
D9
*Account No.

     ?
D10
*Sort Code (xx-xx-xx)
Do not put N/A

     ?
E1
*Please explain the individual's background

      
E2
*What are the family circumstances?

      
E3
*Are there any medical, domestic or behavioural issues?

      
E4
*What is your agency's involvement?

      
E5
*Why is assistance sought?

      
E6
*Why is the individual unable to afford the item?

      
F1
*Please upload your covering letter of referral

        
F2
*Please upload the individual's latest bank statement

        
F3
*Please upload the individual's latest benefits statement

        
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