Hardship support scheme application form Step 1 of 8 12% 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(Required) Street Address Address Line 2 City Post Code Email address(Required) Contact Number(Required)Relationship 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) Do you have recourse to public funds?(Required)YesNoNo recourse to public funds is a condition imposed on people who are subject to immigration control in the UK and means you will not be able to claim most benefits, tax credits or housing assistance.Contact Number(Required)Email address(Required) Address(Required) Street Address Address Line 2 City Post Code How long have you lived in this property (approx. date you moved in to property)?(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your current housing status?(Required)SelectHomelessLiving with family or friendsLiving with ParentsLodgerOwner - OccupierResidential CareTemporary AccommodationTenant: CouncilTenant: Housing AssociationTenant: Private landlordHow long have you been a resident of Newham (approx. date you moved in Newham)?(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you applied for Emergency support in the last 6 months?(Required)SelectYesNoHow did you hear about us?(Required)SelectAdults Social CareAge UKAnchor House - CaritasBenefits (HB & CTR)Children's CentreChilldren and Young People's ServicesClient AffairsCommunity HubCommunity LinksCommunity Mental Health TeamCouncil TaxCouncil Tax Letter – BIPCouncil Tax SMS – BIPCT/HR InsertCustomer Services OfficerD&BAS debt/benefits adviceDebt Advice SurgeryDomestic Violence agencyEnabled LivingEvent - Lets Talk About MoneyFamilyFood BankFriendHomelessness - HPASHousing - Rent ServiceHousing Rent Letter– BIPHousing Rent SMS – BIPJob CentreLBN Carers Support TeamLeafletLocal Service CentreMP/CouncillorNewham Food AllianceNewham LibraryNewham MagazineNewham People FirstNewham Resident ServicesNewham ShowOur Newham Money InternalOur Newham WorkOutreach - Beckton LibraryOutreach - Canning Town LibraryOutreach - Forest Gate LibraryOutreach - Manor Park LibraryOutreach EventShelterShineSocial PrescribeSomali AssociationStratford Advice ArcadeSwan Housing AssociationTelecareTroubled FamiliesWalk InWebsiteWelfare Support TeamOther (Please specify below)Other how did you heard about us?(Required) Household DetailsWho is the main claimant in the household?(Required) By main claimant we mean the person in the household is the main bill payer and main claimant for benefits purposes.Do 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 5HiddenHow many adults live in your house? Employment & BenefitsWhat is your current employment status?(Required)SelectIn 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 contractOur Newham Money provide an Employment Rights advice service. Do you require any information or guidance in this area (such as entitlement to sick pay/unpaid wages)?(Required)SelectYesNoHiddenWhat benefits do you currently receive?(Required)SelectNOT 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 BenefitsWhat benefits are you currently receiving?(Required)Please tick all benefits that you are currently receiving NOT Claiming Any Benefits Attendance Allowance Carers Allowance Child Benefits Child Tax Credit Council Tax Benefits Disability Living Allowance (DLA) Employment Support Allowance (ESA) Housing Benefits Incapacity Benefits Income Support Job Seeker Allowance (JSA) Pension Credit Personal Independence Payment (PIP) Universal Credit (UC) Other Benefits Specify Other benefits(Required) When is your next payment due?(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Income & ExpenditureIncome (Monthly) Use this page to tell us about where, and on what, you and/or your partner spend your money. You MUST include things like: food, gas and electricity, bills and debt repayments. This information is needed to help us work out how much money you have left over each week. If you do not provide full and complete details of the money you spend, it is likely that your application will be rejected. Do not include any money that may already be taken from any benefit that you get Wages/Salary(Required)Wages/Salary (Partner)(Required)If your partner does not work please input £0.Universal Credit(Required)Tax Credits(Required)Job Seekers Allowance(Required)Employment Support Allowance(Required)Income Support(Required)Child Benefit(Required)Disability Benefits(Required)Other State Benefits(Required)State benefits mentioned on the previous page or any other benefits.Any other income (please specify) AmountCapital/Savings (please specify) AmountExpenditure (Monthly)Rent(Required)If not applicable please input 0Mortgage(Required)If not applicable please input 0Council Tax(Required)If not applicable please input 0Gas(Required)If not applicable please input 0Electricity(Required)If not applicable please input 0Water(Required)If not applicable please input 0TV Licence(Required)If not applicable please input 0Food/Household items(Required)If not applicable please input 0Broadband/TV packages(Required)If not applicable please input 0Phone (Mobile)(Required)If not applicable please input 0Travel expenses(Required)If not applicable please input 0Any other outgoings (please specify) AmountDebtsType of debt (please specify) Combine all debts if more than oneAmountMonthly repayments Support RequiredWhat support are you requesting?Food(Required) Yes No Energy(Required) Yes No HiddenWhite Goods Yes No HiddenHelp you need (please select one from the drop down list)(Required)SelectEnergyFood AssistanceWhite GoodsWho 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?Details of what support you require and why?(Required)Your 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:(Required)SelectSupermarket Voucher issued via emailBAC’s payment (Bank Transfer)(Please note that confirming your payment option is not a confirmation of award)Please provide the last 4 digits of your (applicant) account number which you would like to receive payment if your application is successful.(Required) 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 last 2 months’ bank statements for every account held. Make sure your name, address and account number is clearly visible.(Required) 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.Please provide recent utility bill e.g. gas, electricity or water supplies.(Required) Drop files here or Select files Accepted file types: jpg, gif, png, bmp, pdf, Max. file size: 256 MB, Max. files: 3. HiddenProof of ID Drop files here or Select files Accepted file types: jpg, gif, png, bmp, pdf, Max. file size: 10 MB. Photo ID 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.