Food Help Application Form

"*" indicates required fields

Food help information

Foodbanks in Somerset provide short-term food assistance for people facing food poverty. As a referring advice agency our role is to address the underlying cause(s) of your financial difficulties and establish if food help can be provided.
Access to food assistance will be based on the outcome of this application form.
You may be required to provide evidence of financial need. An adviser will discuss this with you when we receive your form.

About your data

In 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.

Explicit Consent

The details of your case may contain personal and special category data.
Personal data is data which can be used to identify you. This may include your name, date of birth, address, telephone number, etc.
Special category data is information related to any of the following: racial or ethnic origin, political opinions, religious beliefs, trade union membership, health, sexuality or sex life, offences and/or convictions. We are required to ask you for your explicit consent to hold special category data.

Your Special Category Data

By providing answers to the questions below you consent to Citizens Advice recording the special category personal data you are providing.

Consent to Privacy Policy*

Tick to accept and proceed

About you

Your Full Name*

Prefix First Last

Your Date of Birth*

DD slash MM slash YYYY

Your Address*

Address Line 1 Address Line 2 Village or Town Post Code

Can we write to you at this address?*

Yes

Your Email Address*

By providing your email address you are consenting to be contacted by email.

Enter Email Confirm Email

Can we email you?*

Yes

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.

Please note that if we phone you it may be from a withheld number

Can We Leave a Voicemail if Necessary?*

Yes

Can We Send a SMS Text if Necessary?*

Yes

Your Gender*

Your Gender Description*

Ethnicity*

We know that food insecurity is more prevalent amongst people from black and minority ethnic backgrounds than amongst people who would describe their ethnicity as white. We would like to understand more about who needs food help in Somerset and how this compares to the overall population. Understanding ethnic groups also helps food banks to tailor provision to suit local communities.

By answering this question you are providing consent for Citizens Advice to process and record the special category personal data you are providing.

About your situation

Your Household*

Please select the best option that describes your household. Your household is your family members that live with you.

How 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?*

Age(s) of Children*

Please provide the age of each child, aged 18 or under, that lives in your household. Use the + symbol to add more rows

Age of Child

Name(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 rows

Name of Adult

Please confirm who exactly is in your household (Age and Gender)*

Do you need pet food?*

PLEASE BE AWARE - We cannot guarantee that pet food will be available, however we will ask.

Yes

Please confirm details of your pet/s. (What Animal, how many and what size?*

e.g., 1 large dog, 2 medium cats

Does anyone in your household have any allergies or dietary restrictions (e.g. vegetarian)?*

If a Member of Your Household (i.e., an infant) Requires Formula/Baby Milk, Please confirm the Name and Type of Formula Required.

PLEASE BE AWARE - We cannot guarantee that we will be able to provide Formula, however we will ask.

What cooking facilities do you have?*

Oven

Hob

Microwave

Kettle

None of the Above

Do you need toiletries?*

Yes

Do You Need Nappies? Please Confirm The Size of Nappies You Need*

PLEASE BE AWARE - We cannot guarantee that we can provide these, however we will ask.

Do you have enough food for tonight?*

Yes

Information about the amount of money you have to live on each month....

What is the source of income for the household?*

Please select from one of the following options.

What has happened which means you need a food help?*

Select all that apply

Change in work hours

Unemployment following permanent work

Unemployment following temporary

Delay in or awaiting other income

Benefit delay

Benefit deduction due to overpayment or benefit advance

Benefit reduction due to change in eligibility

Benefit reduction due to sanction

Awaiting first benefit payment for less than a month

Awaiting first benefit payment for more than a month

Priority debt

Non-priority debt

Cost of dependents has increased

Rising cost of essentials

Other unexpected expense

Insecurely housed

No access to financial support due to immigration status

Loss of support from friends or family

Change in relationship status

Domestic abuse

Change in dependents

New physical or mental health condition or issue

Ongoing impact of existing mental or physical health condition

Change in existing mental or physical health condition

None applicable

If you have not spoken with a Citizens Advice advisor today, please tell us more about your situation.

Have you or anybody in your household applied for/received food help in the last 6 months?*

Yes

Can you tell us the reason for needing further help?*

Please explain your reason*

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.

Yes

Their Name*

Prefix First Last

Their Organisation

If the person who helped you fill in this form belongs to an organisation, please provide the name of the organisation

Their Telephone Number

This is the preferred contact number of the person who helped you fill in this form

Their Email Address

Please provide the email address of the person who helped you fill in this form

Agreement*

I understand that I may be asked to provide evidence to support my food help application

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 agree to Citizens Advice Somerset sharing information with my local food back for the purposes of applying for food help.

I confirm.

Food help information

About your data

Explicit Consent

Your Special Category Data

About you

About your situation

Information about the amount of money you have to live on each month....

Completion and Declaration....

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Food help information

About your data

Explicit Consent

Your Special Category Data

About you

About your situation

Information about the amount of money you have to live on each month....

Completion and Declaration....

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