"*" indicates required fieldsClient support fund informationThe client support fund is a discretionary fund providing help in a crisis or at a critical time.Access to assistance will be based on the outcome of this application form and the evidence you provide. As this is a discretionary fund there is no right of appeal if you disagree with the outcome.You will be required to provide evidence to support your application. You can upload photos or screenshots/PDFs with this application form. If you are unable to do this we will contact you to discuss your next steps.The evidence you need to provide is:your ID - e.g. driver's license, passport, council tax or utility bill, andyou live in Somerset - e.g. driver's license, council tax or utility bill, andYour household's income - e.g. recent confirmation of any benefits received, andBank and/or building society transactions for every adult in the household, these must show at least the last 30 days of activity and the current balance on each, andif you are moving to a new property, evidence of your new tenancy agreement that shows your name, the new address, and your move in date.About your dataIn order to process this application, we need to record details of your case. Under GDPR regulations we have a legitimate interest to hold this information in order to help you progress your case. The record of your case will be stored on an electronic case management system accessed by members of the Citizens Advice service. To comply with regulations, we must tell you how we use this data and ask your consent to record your details in this way. You can read about how we use and store your information in our Privacy Policy here.About you and your householdYour Full Name* Prefix DrMissMrMrsMsProf.Rev. First Last Your Date of Birth* DD slash MM slash YYYY Your Gender*Please SelectMaleFemalePrefer a different termPrefer not to sayYour Gender Description*Ethnic Origin*By answering this question you are providing consent for Citizens Advice to process and record the special category personal data you are providing.Please SelectWhite - BritishWhite - EnglishWhite - ScottishWhite - WelshWhite - Northern IrishWhite - IrishWhite - OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianMixed - OtherAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - OtherBlack or Black British - AfricanBlack or Black British - OtherOther - ArabOther - Any OtherUnknownPrefer Not To SayYour Address Address Line 1 Address Line 2 Village or Town Post Code Primary Phone Number*Your preferred contact number. By providing this telephone number you are consenting to be contacted by telephone. PLEASE NOTE: The call may be from a Withheld/Unknown number.Can We Leave a Voicemail if Necessary?* Yes NoCan We Send a SMS Text if Necessary?* Yes NoPlease note that if we phone you it may be from a withheld numberI Have Access to an Email Address* Yes NoYour Email Address*By providing your email address you are consenting to be contacted by email. Enter Email Confirm Email Can We Also Send You a Letter?* Yes NoYour Household*Please select the best option that describes your household. Your household is your family members that live with you.Please Select...Single PersonSingle Person with Dependent ChildrenSingle Person with non Dependent ChildrenCoupleCouple with Dependent ChildrenCouple with Non Dependent ChildrenOther Adults and Non Dependent ChildrenHow many people in total live in your household?*In total, how many people including you live in your household?How many of these people are adults aged 19 or over (excluding cared for adults)*How many of these people are cared for adults aged 19 or over?*How many of these people are children aged 18 or under?*Children*Please provide the date of birth and name of each child, aged 18 or under, that lives in your household. Use the + symbol to add rowsDate of Birth and name of Child Add RemoveName(s) of Other Adults in Your Household*Please provide the names of each adult (over 18) in your Household. Use the + symbol to add more rowsName of Adult Add RemoveInformation about the amount of money you have to live on each month....Is Your Household In Receipt of Means-Tested Benefits?*Means tested benefits are those that you are entitled to if you are on a low income, such as Universal Credit No YesIs Your Household in Receipt of Universal Credit?* Yes NoDo You Have an Online Journal?* Yes NoWhat Legacy Benefits is Your Household in Receipt Of?*These are benefits that pre-date Universal Credit and that you may still be in receipt of Child Tax Credits Council Tax Support Housing Benefit Income-Related ESA Income-Related JSA Income Support Pension Credit (Guaranteed) Universal Credit Working Tax CreditsWhat is the total amount of income your household receives each month?*Household income is defined as all income coming into the household from adults aged 18 or over from earnings, employment and self employment, benefits, pensions and income from savings and investments. Please do not include income from health related benefits such as DLA, PIP and Attendance Allowance. Please also do not include earnings from any young person who is still in full time education (school, sixth form or college) If your household includes 2 or more adults please give the total income for your whole household.Please Select...£799 or less£800 - £999£1,000 - £1,300£1,301 - £1,499£1,500 - £1,999£2,000 - £2,499£2,500 or moreDo you have any savings and capital?*Savings and capital is defined as money you have in bank accounts, in any type of investment (including ISAs), and in ownership of valuable assets such as other property. Please do not include the home you live in or other assets you need day to day such as cars you need for work or childcare. No YesHow much do you have in savings and capital?*What essential support do you need?Please note that this fund is for a crisis or at a critical time, so please ensure you select all that apply to your situation and explain why you need them.The fund is limited, and we can only make one award in a 12-month period (except for prepayment meter top-ups which is two in any 6-month period).Energy essentialsDo you require support with: electricity, gas or other type of fuel and no means of getting any? Yes - please complete the following questions NoPlease confirm how you top up your meter Key Card Smart phone appWho is your energy provider?Cooking essentialsI need basic cooking/eating equipment and no means of getting them cooking utensils (e.g. pans, crockery, cutlery) kettle toaster fridge freezer microwave* tabletop cooker and hob*Note: *only one can be provided ± a cooker can only be considered in exceptional circumstancesFurniture essentialsI need items of essential furniture and no means of getting them cot cot mattress bedding set single bed single mattress single duvet single bedding double bed double mattress double duvet double beddingClothing essentialsI need clothing and have no way to obtain this school uniform warm clothing for winter (or essential clothing if lacking this) job interview clothesLaundry essentialsI need laundry help washing machine^ heated drying rack condensing tumble dryer*Note: ^ to be considered for a washing machine you will need to demonstrate you have a medical condition that requires additional washing/laundry * you will need to show that there is a health need or baby/young child in the homeIdentityI need proof of ID and can’t afford to get it provisional driving licence Citizens Card birth certificatePlease tell us why you need the help requested above*Evidence to support your application....Applications will not be considered without the necessary supporting evidence.Important:Evidence showing your address must show your current addressPhotographs or scans of paper-based evidence, such as letters, should be dated within the last 6 months and must show your name and addressBank or building society evidence must cover a full calendar month and show your current balance. Screenshots of online banking must show your name as well as the transactions. You can upload multiple screen shots if required. If you or household members have more than one account, please upload the latest statement for each accountAgreement* I understand I need to provide evidence to support my application.Please tick which evidence you are uploading Proof of ID (Driver's License, Passport, Utility Bill, Benefit letter or similar) Proof of Address (Driver's License, Bank Statement, Utility Bill or similar) Proof of your household income, e.g. recent confirmation of any benefits received Bank or building society statements for every adult's accounts in the household that shows the last month of activity and the current balance on eachDocuments Missing?If you are unable to upload some or all of the documents, please tick this box. We will contact you to talk about your next step options. I am unable to upload some or all of the documentsDocuments Upload Drop files here or Select filesAccepted file types: jpg, pdf, png, doc, docx, Max. file size: 5 MB.Completion and Declaration....Did Someone Help You to Fill in This Form?*This could be a friend, a family member, or a member of an organisation. Please provide their details below. Please note that their details will be stored confidentially along with your application. No YesTheir Name* Prefix DrMissMrMrsMsProf.Rev. First Last Their Organisation*If the person who helped you fill in this form belongs to an organisation, please provide the name of the organisationTheir Telephone NumberThis is the preferred contact number of the person who helped you fill in this formTheir Email AddressPlease provide the email address of the person who helped you fill in this form 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 Somerset 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 confirm.
