Household Support Fund Form

"*" indicates required fields

Are you a resident in the BCP Council area?*

Yes

If you are not a BCP resident please contact your Local Authority for details of their HSF scheme.

Have you or anyone in your household applied to the Household Support Fund in 2024?*

Yes

Please provide the date of the application and the outcome*

Permissions & Consent*

Yes, I consent to you holding the information I have provided.

Yes, I consent to you contacting me by email and/or telephone if required.

Yes, I give my explicit consent to pass only such information to Evouchers that is essential in order to process my application and issue the vouchers.

When we record and use your personal information, we:

only access it when we have a good reason

only share what is necessary and relevant (see above)

don't sell it to commercial organisations

we'll make sure all your information is kept safe in our secure case management system.

we need to record information about you to help with your application. We have a legitimate interest to do this. If you would like more information about how we will use your data please see our privacy policy : https://www.citizensadvicebcp.org.uk/privacy-cookies/

Please note that without these consents we are unable to process your application.

I confirm.

Applicant Information

Name*

Prefix First Last

Address*

Street Address Address Line 2 City County Postal Code

Date of Birth*

Day

Month

Year

National Insurance Number*

It is important that we are able to quickly and easily contact you to avoid any delays to your application. Wherever possible we will contact you by email.

Email Address

Grants are provided by email. If you do not have an email please complete the section below to nominate a trusted family member or friend to receive your grant.

Enter Email Confirm Email

Phone Number*

Landline or mobile

Nominee Information

Nominee Name

Prefix First Last

Nominee Address

Street Address Address Line 2 City County Postal Code

Nominee Email Address

Enter Email Confirm Email

Is Nominee aware?*

I confirm that this person is aware and has given me permission to provide this information for the purpose of processing this application.*

Household Information

How many adults are in your household?*

Please enter a number greater than or equal to 1.

How many non-dependent (Above 18 years old) children are in your household?*

Please enter a number greater than or equal to 0.

How many dependent (Under 18 years old) children are in your household?*

Please enter a number greater than or equal to 0.

How many people are of pensionable age in your household?*

Please enter a number greater than or equal to 0.

How many people are classed as disabled in your household?*

Please enter a number greater than or equal to 0.

Household Budget

Please add the income information for each member of your household above 18 years old. Please give MONTHLY figures. Kindly input the accurate figures as we may request for proof of the information you have supplied.

Income and Benefits*

(Please add all income for all members of the household i.e. wages, pensions, and benefits, EXCLUDING ANY HOUSING BENEFITS or Housing elements of Universal Credit) IF IT IS PAID DIRECTLY TO YOUR LANDLORD

Please enter a number greater than or equal to 1.

Rent*

If you are in receipt of HOUSING BENEFITS or Housing element of Universal Credit , please input THE AMOUNT YOU ACTUALLY PAY towards your rent (if it does not cover your full rent).

Mortgage*

If this does not apply to you, please state ''0''.

Council Tax*

Gas and/or Electric*

Water and Sewerage*

TV/Internet/Phone bills*

Food/Groceries/Toiletries*

Pet Costs*

School Costs*

Transport & Travel*

Medical*

Monthly debt repayments OR any other monthly payments you are making*

Total Outgoings*

This field is hidden when viewing the form

Total Incoming minus Outgoings*

Please upload a form of ID

Please provide evidence of ID for the person in your household who is applying for the grant. Upload one of the following; Driving Licence/passport/birth certificate/Council Tax Bill
If you're finding any difficulties uploading an ID, please email a copy of the ID to [email protected]

Accepted file types: jpg, jpeg, pdf, png, Max. file size: 10 MB.

Please upload proof of address

Please provide MOST RECENT proof of address (within the last 3 months) for the person in your household who is applying for the grant. Upload one of the following; Driving Licence/Council Tax Bill/Bank Statement/Benefit letter/Utility bill/GP or NHS letter
If you're finding any difficulties uploading your document, please email a copy to [email protected]

Accepted file types: jpg, jpeg, pdf, png, Max. file size: 10 MB.

Choice one of the following options of the support you require*

Please note - if you are paying via DIRECT DEBIT, we will be UNABLE to issue the voucher.

4 energy vouchers worth £49 each (prepayment or key only)

Supermarket voucher worth £200

Please select which supermarket you would prefer:*

Please be mindful that only Asda and Sainsbury's will accept this voucher to be used online.

Aldi

Asda

Iceland

Tesco

Morrisons

Sainsburys

Your Energy Provider

Please advise which energy provider you use*

How do you pay your energy provider?*

Prepayment: Utility top-up Card

Prepayment: Key

Other

Would you like additional support and information about what to do in the following situations?:

Would you like to speak to Citizens Advice Bournemouth Christchurch & Poole about?

Threatened homelessness within 7 days

Bailiffs calling

Domestic violence

Would you like to contact you about this emergency?*

Please note - Having one of these emergencies does NOT improve your chances of receiving the HSF voucher.

Yes

If yes, how would you like us to contact you?*

Do you think you will benefit from any of the following support:

Food Bank*

If think you will be out of food within a couple of days, we may be able to help you with a Food Bank voucher.

Yes

LEAP (Local Energy Advice Partnership)*

LEAP (Local Energy Advice Partnership) is a FREE home visit scheme to assist residents throughout Dorset with free energy advice, energy saving devices, along with access to other improvements like heating upgrades, insulation, free appliances and replacement boilers.

Yes

Energy Unit*

Due to Energy price crisis, Citizens Advice created a new specialist project to support people in need of specialist advice. If you need advice regarding your Energy bills, please choose this option to be referred.

Yes

Do you have any debts that you would like advice managing?*

Citizens Advice BCP has a dedicated Debt Team who can help you look at your financial situation regarding debt. If you are struggling with debt issues, debt assessment please consider utilising that option to improve your situation long term.

Yes

If you need advice on any areas not covered above, then please visit https://www.citizensadvicebcp.org.uk/get-advice/

Declaration*

I confirm that the information I have provided in this application is accurate and a true representation of my/our household. I agree to Citizens Advice contacting me via the method(s) I have provided, and also contacting anybody who I have stated helped me to complete this form, where necessary to assist in processing the application. I understand that where BCP Council suspects that fraud may have occurred it will investigate the matter as appropriate and this may lead to criminal proceedings. If I attempt to claim an award from the Household Support Fund by making a false declaration or providing false evidence I may have committed an offence under the Theft Act 1968.

I confirm.

Name

This field is for validation purposes and should be left unchanged.