LOCAL DISCRETIONARY WELFARE SUPPORT APPLICATION FORM

Transcription

1 LOCAL DISCRETIONARY WELFARE SUPPORT FUND APPLICATION FORM Applicant 1 Full Name: National Insurance No.: Address: Telephone No.: Ref: Currently in employment? Yes/No Partner Full Name: Address: National Insurance No.: Currently in employment? Yes/No Telephone No.: Children 1. Name: 2. Name: 3. Name: 4. Name: 5. Name:

2 Please explain why you need help from the fund and what help you are asking for - e.g. do you need rent in advance, household items, help with resettlement etc? (Please continue on separate sheet if necessary).

3 Have you received previous help from the Social Fund by way of a Crisis Loan/Community Care Grant? If so please give details of the dates you had these payments and the reason you needed them. If you are asking for help with your rental costs please provide the following information:- The address for which you are asking for Rent in advance/deposit: The reason you are moving to this address: NB any awards for rent in advance and deposits will only be paid directly to a Landlord. You will need to ask your Landlord to provide the council with their full name, address and the bank account details that they want the money paid into.

4 Please list below full details of income from all sources received by you and your partner. If you receive Income Support, please give details of how this is made up e.g. pension, attendance allowance, etc. Full details of all expenditure that you and your partner have (include housekeeping costs, fuel, loans, credit cards, etc.) Weekly income Weekly expenditure IS/JSA/ESA Rent State Retirement Pension Council Tax Pension Credit Life Insurance Wages for you Building/Contents Insurance Wages for your partner Car Insurance Child Benefit Gas Child Tax Credit Electricity Working Tax Credit Water Rates DLA (mobility) TV Licence DLA (care) Fines Attendance Allowance Hire Purchase Maintenance Maintenance Carer s Allowance Childcare Costs Private Pension Adult Care Costs Voluntary/Charitable payments Other Utilities (coal, oil, gas etc) Other (please give details) Home Phone Mobile Phone Broadband Road Tax Petrol Parking Fees Food/Household groceries Other (please give details) Weekly Total Weekly Total Income Expenditure = Please give details of all your bank/savings accounts and amounts held. You will need to provide current bank statements:

5 I declare that the information I have given on this form is correct and complete. I understand that if I knowingly give information that is incorrect I may be asked to repay any amounts awarded to me and may be prosecuted. Signed:... Date:... If you have completed this form on behalf of the applicant please provide your: Name: Relationship to applicant: (e.g. Appointee, Support Worker, family member etc) Reason you are completing the form: Signed:... Date:... The information supplied on this form and gathered during interviews relating to this application, will be held by South Hams District Council and used to make a decision regarding the request for an award from the fund. I/We give our permission for South Hams District Council to share with and/or seek information about me and/or my family from other external agencies in respect of this application. These may include police forces, under the Crime and Disorder Act This agreement is based upon my understanding that due care will be taken to obtain and disclose only that information that is relevant to my application and delivering a service to me and/or my family. I understand that all information about me and my family will be held by the Council in accordance with Data Protection legislation. I/we understand that South Hams District Council has a responsibility to protect public funds which they handle, therefore, I/we agree that they may use the information provided on this form to prevent and detect fraud. I/we agree that South Hams District Council may also share this information, for the same purposes, with other organisations which handle public funds. Any information provided may also be used to check the accuracy of other records held by South Hams District Council including Council Tax and Housing Benefit records. Please note that you may be contacted by another agency in respect of this application who will ask for feedback from you on the application process. If you wish to see the personal data the Council holds please telephone (01803) and ask for the Council s Data Protection Officer. Signed:... Date:...

6 Office Use Only Recommendation & Reasons: Signed:... Date:... Spreadsheet completed Form scanned on to Anite Payee Name, Address & Bank Details obtained Decision & Award: Signed:... Senior Officer Date:...