Emergency support application form Reference Number Name* TitleMr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Date of birth* DD slash MM slash YYYY National Insurance Number* Address* Street Address Address Line 2 City Post Code Contact Number*Email address* How long have you lived in Newham (approx. date you moved in Newham)?* DD dash MM dash YYYY Ethnicity*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 sayWhat is your current employment status?*Please select one...In Training or EducationJobseekerNever WorkedRetiredSelf EmployedUnemployedUnfit for WorkWorking Full Time (over 30 Hours)Working Part Time (16-29 hours per week)Working Part Time (less than 16 hours per week)Zero hour contractWhat is your current housing status?*Please select one...HomelessLiving with family or friendsLiving with ParentsLodgerOwner - OccupierResidential CareTemporary AccommodationTenant: CouncilTenant: Housing AssociationTenant: Private landlordWhat benefits do you currently receive?*Please select one...NOT Claiming Any BenefitsAttendance AllowanceCarers AllowanceChild BenefitsChild Tax CreditCouncil Tax BenefitsDisability Living Allowance (DLA)Employment Support Allowance (ESA)Housing BenefitsIncapacity BenefitsIncome SupportJob Seeker Allowance (JSA)Pension CreditPersonal Independence Payment (PIP)Universal Credit (UC)Other BenefitsWhen will the next payment be made?* DD dash MM dash YYYY How many adults live in your house?*How many children live in your house?*012345More than 5If no children live in your home please enter 0.Help you need (please select one from the drop down list)*SelectEnergyFood AssistanceHome Appliances - White GoodsWho is your current Energy Provider*SelectBritish GasEDFe.OnOtherHiddenIf you require food assistance please tick this box Require food assistance Anything else you would like to tell usConsent* I consent to my data being collected and stored*
