Cost of Living Hardship Support Application Step 1 of 6 16% Are you completing the form on someone's behalf?(Required)NoYesIf yes, please complete the below declaration. Unless explicitly stated, the questions on the rest of the form are now directed to the applicant (person that you are applying on behalf of).Name(Required) Mr.Mrs.MissMs.Mx.Dr.Prof.Rev.Prefer to specify Title First Last Specify Title Address Street Address Address Line 2 City Post Code Email address(Required) Contact NumberRelationship to the applicant(Required) Please tell us why you have completed the form on the applicants behalf(Required) Declaration(Required) By ticking I declare that I have confirmed with the person claiming that the answers I have given on this form are correct Applicant's DetailsName(Required) Mr.Mrs.MissMs.Mx.Dr.Prof.Rev.Prefer to specify Title First Last Specify Title National Insurance Number(Required) Date of birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)SelectMaleFemaleTransgenderNon-binaryPrefer to specifySpecify Gender Ethnicity(Required)SelectAsian or Asian British BangladeshiAsian or Asian British IndianAsian or Asian British Other BackgroundAsian or Asian British PakistaniBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British Other BackgroundChineseMixed Other BackgroundMixed White & AsianMixed White & Black AfricanMixed White & Black CaribbeanWhite BritishWhite IrishWhite OtherPrefer not to sayIf other Ethnicity selected please specify(Required) Contact Number(Required)Email address(Required) Address(Required) Street Address Address Line 2 City Post Code Household DetailsDo you have a partner?(Required)SelectYesNoBy partner we mean someone you are married to or have a Civil Partnership with or lives with you as if you were married. Partner Name(Required) MissMrMrsMsMx.DrProf.Rev.Prefer to specify Title First Last Partner Specify Title(Required) Partner Date Of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Partner National Insurance Number(Required) Do you have any children?(Required)SelectYesNoHow many children live in your house?(Required)Select012345More than 5If no children live in your home please enter 0.Any other adults in your household?(Required)SelectYesNoHow many adults?(Required)Select012345More than 5 Support RequiredWhat support are you requesting?Food(Required) Yes No Energy(Required) Yes No White Goods / Warm Items(Required) Yes No Who is your current Energy Provider(Required)SelectBritish GasEDFe.OnOtherIf Other energy provider selected please specify(Required) Do you have any Energy arrears?(Required)SelectYesNoHow much?If you would like to provide any further details of the support you require, please use the box below.HiddenYour application will be processed and we will contact you with the outcome. If your application is successful would you like the award to be made via:SelectSupermarket Voucher issued via emailBAC’s payment (Bank Transfer)(Please note that confirming your payment option is not a confirmation of award)HiddenPlease provide the last 4 digits of your (applicant) account number which you would like to receive payment if your application is successful. Please ensure you upload the bank statement for this account in the evidence required on the next page.*If you are awarded the Council Tax Rebate Discretionary fund and it is paid directly into your bank, if your account is overdrawn or you have an overdraft, you have the right of 'appropriation' to stop the Rebate payment being used against it. You will need to put this in writing to your bank, to inform them that you wish to use the Rebate payment to pay certain bills. More information and a template to help you contact your bank are available at National Debtline. Please note each claim will be considered on its merits within the funding available when the application is processed. EvidencePlease provide most recent bank statements. Make sure your name, address and account number is clearly visible. Drop files here or Select files Accepted file types: jpg, gif, png, bmp, pdf, Max. file size: 256 MB, Max. files: 6. This includes joint accounts and accounts held with similar institutions such as building societies and the Post Office and accounts held abroad. These will be used to verify the information you provide on your application. ConsentWhat you are agreeing to when you submit this form This form represents a contract between you and the London Borough of Newham, Our Newham Money, its contractors, consultants, other agencies (Council Partners), and external funders to share information provided by you to Our Newham Money in order to provide the services and benefits to you as described on this form. If you want a copy of the information we hold about you or have any question about your personal data please speak to your advisor or contact us by email firstname.lastname@example.org, alternatively you can visit Newham website to read more about our Privacy & Data Processing Notice. >Consent(Required)How we use your personal information? Information which you provide or which we obtain through your dealings with us will be held securely with Our Newham Money. We will use your information as applicable and this may include: Keep in contact with you and provide you with the best service you deserve Our Newham Money may pass your personal data to London Community Credit Union when you have applied for a loan through Our Newham Money Inform you of suitable information or support which may be available Our Newham Money may refer you to other council departments and third party organisations where we feel you may benefit from their services and we may pass your details to them Debt counselling or other specialist service providers if needed The Department for Work and Pensions or HM Revenue and Customs Data Processors who act on our behalf Produce reports and statistics relating to Our Newham Money activities We retain personal information for as long as is necessary Tell us immediately if there is a change in your circumstances To find out more about how we process personal information, please read our Privacy & Data Processing Notice By ticking this box you are giving your consent/agreeing to your personal information being used in this way. Evaluation (This is optional)Evaluation Our Newham Money may pass your personal contact details on to an organisation responsible for evaluating Our Newham Money. If so, the evaluation report may be presented by Our Newham Money in either an anonymised report or a report containing some identifying characteristics. If contacted by the Our Newham Money evaluation organisation you may refuse to be included in the evaluation report, but in order to get the most representative view, Our Newham Money would appreciate you agreeing to this request. By ticking this box you are giving your permission to Our Newham Money to pass on your details to external Evaluators. Information & Invitations (This is optional)Information and Invitations From time to time Our Newham Money may wish to provide customers with additional information about services, which may be relevant to their financial needs such as products, events or associated services. Also, we may wish to invite customers to events or celebrations relating to Our Newham Money or wider Newham activities. This information will normally be sent by email but may occasionally be by phone or a letter. By ticking this box you are giving your permission for Our Newham Money to send general information or invitations. DeclarationDeclaration(Required)Information Statement To the best of my/our knowledge and belief the information that I/we have provided on this form is true, complete and correct. I/we understand that that the information I/we have provided in completing this form is used in determining my/our eligibility for Emergency Assistance. Knowingly providing false or misleading information or omitting information that I/we were under a legal duty to disclose for the purpose of gaining emergency assistance may be regarded as a criminal offence, and action could be taken against me/us including court action. Money must be used for intended purpose only. By ticking this box you are agreeing to the information statement above.