Enable customers suffering from the effects of self-isolation and 'shielding' to be able to apply for support from the funds that the government has made available to local authorities.

Details within the form can be emailed directly to an inbox of your choosing. 

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Emergency Hardship Service

Your reference is XRRFGZGG

About you/your household

Are you a UK Resident?

   Yes   No  

Are you aged under 16?

   Yes   No  

Do you live in the council area or are you planning to move here in the next six weeks?

   Yes   No  

Are any of the following relevant to you :

Fleeing domestic violence

Physically disabled or suffering from a mental health condition

Learning disability or acquired brain injury, and receiving Disability Living Allowance or Personal Independence Payment

Terminally ill

Vulnerable for another reason

None of the above

What is your current living situation?

I own my own home

I rent from a housing association or the council

I rent from a private landlord

I live in a hostel

I live in supported accommodation

Other

Provide details(optional)

Who are you

First name

Surname

DateOfBirth

Address Line 1

Address Line 2

Address Line 3

Address Line 4(optional)

Postcode

Mobile Telephone Number

Are you disabled and receive a DWP benefit as a result of this?

   Yes   No  

Tell us your claim reference(optional)

Have you claimed before?

   Yes   No  

When did you claim?

Which council?

Do you have a partner?

   Yes   No  

Does anyone else live with you?

   Yes   No  

Please use this box to tell us anything else about you and your family you think might be relevant(optional)

  

Emergency Hardship Service

Your reference is XRRFGZGG

Support you need

Are you applying for help with an item of furniture?

   Yes   No  

Are you applying for help towards food?

   Yes   No  

Are you applying for help towards Gas or Electric

   Yes   No  

Are you applying for expenses towards something else?

   Yes   No  

Please tell us what the emergency/crisis is and the effect that it has had

Have you tried to get any other support?

   Yes   No  

What are the risks to you (and your family, if you have one), if you don’t get any support?

Is there anything else you can tell us to support your application?(optional)

What help or support would help you avoid being in this situation again?(optional)

Do you need help with any skills or training?

   Yes   No  

  

Emergency Hardship Service

Your reference is XRRFGZGG

Support you need

Are you applying for help with an item of furniture?

   Yes   No  

What furniture do you need?

Tell us what furniture you need

Are you applying for help towards food?

   Yes   No  

Are you applying for help towards Gas or Electric

   Yes   No  

Are you applying for expenses towards something else?

   Yes   No  

Please tell us what the emergency/crisis is and the effect that it has had

Have you tried to get any other support?

   Yes   No  

What have you applied for and what have you received?

What are the risks to you (and your family, if you have one), if you don’t get any support?

Is there anything else you can tell us to support your application?(optional)

What help or support would help you avoid being in this situation again?(optional)

Do you need help with any skills or training?

   Yes   No  

  

Emergency Hardship Service

Your reference is XRRFGZGG

About Money

Income

How many separate income types do you have? E.g. Income Support would be 1. Earnings would be 1. Child Benefit would be 1(optional)

  1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20  

For each income

What is it?

How often do you get it?

   Weekly   Fortnightly   4 weekly   Monthly   Quarterly   Annually  

How much do you get?

Who recieves this income?

   Me   Partner  

Do you have any money in the bank/savings at all?

   Yes   No  

Outgoings and Debts

We need to know what your outgoings are. Please see the list below and enter the amount you spend each week for each item. If you do not have an expense please enter 0.00

Council TaxHelp(optional)

RentHelp

MortgageHelp

ElectricityHelp

GasHelp

Water ChargesHelp

GroceriesHelp

ToiletriesHelp

TV LicenceHelp

TV Rental (for example Brighthouse or similar)Help

Landline Telephone ChargesHelp

Mobile Telephone CostsHelp

Broadband e.g. Sky/Virgin Media/BT etcHelp

Public Transport ExpensesHelp

Taxi FaresHelp

Petrol/DieselHelp

Car InsuranceHelp

Road TaxHelp

MOTHelp

Car Repairs/serviceHelp

School MealsHelp

ChildcareHelp

Maintenance PaymentsHelp

ClothesHelp

Washing/LaundryHelp

Building and Contents InsuranceHelp

Life Assurance/EndowmentHelp

Prescription/Health CostsHelp

Ground RentHelp

Second mortgage or secured loanHelp

Unsecured Loan e.g payday loanHelp

Catalogue RepaymentHelp

Magistrates Court Fine PaymentHelp

Do you have any other expenses?

   Yes   No  

What is the total weekly amount you pay?Help

Outstanding Debts/Charges

Do you have any outstanding Debts?

   Yes   No  

Please upload any evidence you think will help support your application e.g. bank statements / proof of debts etc.

No files uploaded

Do you need help with making or managing a budget?

   Yes   No  

  

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