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Title *Please select one...MrMrsMissMs

Full Name *

First

Last

Date of birth *

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Age Category

• Age 18 to 24
• Age 25 to 29
• Age 30 to 34
• Age 35 to 39
• Age 40 to 44
• Age 45 to 49
• Age 50 to 54
• Age 55 to 59
• Age 60 to 64
• Age 65+

National Insurance Number *

Landline Number

Mobile Number *

Email *

Gender *Please select one...FemaleMaleOtherPrefer not to say

Ethnicity *Please select one...English, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black, African or Caribbean backgroundArabAny other ethnic groupPrefer not to say

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

How long have you lived in Newham (approx. date you moved in Newham)?Please selectMore then 6 monthsLess then 6 months

How many children live in your house? *

If no children live in your home please enter 0.

How many children under the age of 18 live with you? *Please select one...None1234 or more

How many adults live in your house? *

If no adults live in your home please enter 0.

What is your current housing status? *Please select one...HomelessLiving with family or friendsLodgerOwner - OccupierResidential CareTemporary AccommodationTenant: CouncilTenant: Housing AssociationTenant: Private Landlord

What is your current employment status? *Please select one...In Training or EducationJobseekerNever WorkedRetiredSelf employedUnemployedUnfit for WorkWorking Full TimeWorking Part TimeZero Hour Contract

What benefits do you currently receive?

• No Recourse to Public Funds
• Not Claiming Benefits
• Attendance Allowance
• Carers Allowance
• Child Benefits
• Child Tax Credit
• Council Tax Benefits
• Disability Living Allowances
• Employment Support Allowance
• Housing Benefits
• Incapacity Benefits
• Income Support
• Job Seekers Allowance
• Pension Credit
• Personal Independence Payments
• Universal Credit
• Other Benefits

Please select categories that apply to you

How has the cost of living crisis affected you? *

Please select categories that apply to you

• Living in poverty
• Homeless
• Learning difficulties
• Mental health issues
• Physical difficulties
• Victims of crime/violence/abuse
• Children and young people
• Families/Parents/Lone parents
• LGBT groups
• Long-term unemployed
• In care or suffering serious illness
• People with multiple disabilities

Please provide proof of address *

Click or drag a file to this area to upload.

Select type of document uploaded *Please select one...Recent utility billUK full or provisional photo-card driving licenceMost recent HM Revenue and Customs tax notificationFinancial statement (e.g. bank, building society, credit card or credit union statement) containing current addressRecent benefit letter from Department of Work and Pensions (DWP) confirming the rights to benefit (for example, child allowance, pensionCurrent local council rent card or tenancy agreementConfirmation from an electoral register search that a person of that name lives at the claimed address

Purpose of the support *

• Food
• Energy
• Clothing
• Other essential

Have you previously received or applied for funding from the Household Support Fund from other agencies? *

• Yes
• No

In order to understand the impact of our grants and how we can help others, please confirm that we can contact you regarding how we have assisted. *

• Yes
• No

I confirm that the information I have supplied is true and correct to the best of my knowledge. I understand that any false or undisclosed information could result in the closure of my application for assistance. *

• Confirm

Legal and Preference: Keeping in touch - We would like to keep you posted on our latest news about financial help available, our work, appeals and campaigns. Please let us know how you would like to hear from us: *

• Email
• Telephone
• SMS

Consent Agreement *

• I consent to my data being collected and stored and shared with relevant authorities.

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