"*" indicates required fieldsThe Local Assistance Scheme for Somerset provides help in emergencies only for basic living items like food, furniture/ appliances, fuel for cooking and heating. Access to assistance will be based on the outcome of this application form and related eligibility criteria.PLEASE NOTE: If your application is only for food, evidence may not be required. We will require some evidence with the submission of this form. This can be photos or screenshots/PDFs. The evidence required is: - Proof of ID (Driver's License, Passport, Utility Bill 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 statements for every adult's accounts in the household that shows the last month of activity and the current balance on each Please note - If you are moving to a new property, please provide evidence of the page of your new tenancy agreement that shows your name and the new address To apply please select the local Citizens Advice for the area you live in*Please Select...Sedgemoor AreaSouth Somerset AreaTaunton Area (Taunton, Wellington, Norton Fitzwarren, Wiveliscombe & near by)West Somerset Area (Minehead, Watchet and Williton & near by)Mendip AreaIn order to process this application, we need to record details of you/r client. This will include ‘personal data’ (information which can be used to identify you/your client, such as your/their name, date of birth, contact details, etc.) and may include Special Category Data such as Health Conditions, We will discuss our use of the information further with you/your client when we first make contact.The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the you/your client to record those details. To submit this form, you must have give/have gained consent to send us all the information you have provided below.For more information about what we do with your information please read our Privacy Notice. click hereIn order to process this application, we need to record details of you/r client. This will include ‘personal data’ (information which can be used to identify you/your client, such as your/their name, date of birth, contact details, etc.) and may include Special Category Data such as Health Conditions, We will discuss our use of the information further with you/your client when we first make contact.The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the you/your client to record those details. To submit this form, you must have give/have gained consent to send us all the information you have provided below.For more information about what we do with your information please read our Privacy Notice. click hereIn order to process this application, we need to record details of you/r client. This will include ‘personal data’ (information which can be used to identify you/your client, such as your/their name, date of birth, contact details, etc.) and may include Special Category Data such as Health Conditions, We will discuss our use of the information further with you/your client when we first make contact.The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the you/your client to record those details. To submit this form, you must have give/have gained consent to send us all the information you have provided below.For more information about what we do with your information please read our Privacy Notice. click hereIn order to process this application, we need to record details of you/r client. This will include ‘personal data’ (information which can be used to identify you/your client, such as your/their name, date of birth, contact details, etc.) and may include Special Category Data such as Health Conditions, We will discuss our use of the information further with you/your client when we first make contact.The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the you/your client to record those details. To submit this form, you must have give/have gained consent to send us all the information you have provided below.For more information about what we do with your information please read our Privacy Notice. click hereIn order to process this application, we need to record details of you/r client. This will include ‘personal data’ (information which can be used to identify you/your client, such as your/their name, date of birth, contact details, etc.) and may include Special Category Data such as Health Conditions, We will discuss our use of the information further with you/your client when we first make contact.The information will be stored on a shared electronic case management system accessed only by members of the Citizen Advice service. To comply with data protection legislation, we must ensure there is consent from the you/your client to record those details. To submit this form, you must have give/have gained consent to send us all the information you have provided below.For more information about what we do with your information please read our Privacy Notice. click hereConsent to Privacy Policy* Tick to accept and proceedInformation about you and your household....Your 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 Have you or Anybody in Your Household Applied for/Received LAS in the Last 6 Months?* No YesPrimary 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?*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 rowsAge 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 appreciate that this fund is for the use of people experiencing a crisis and are unable to purchase essential items for their homes. Other than food parcels, we are limited to providing two awards in 6 months, so please ensure to detail all the essentials you will need.I/We Need A Food Parcel*We may need to share your personal information with your local foodbank provider.Please Select...Yes, only a food parcelYes, but also other items/supportnoAs part of the referral process for a food parcel we need you to provide the information below:Exactly who is in your household? (Including their age and gender)*Do You Need Pet Food?*PLEASE BE AWARE - We cannot guarantee that the food bank will be able to provide pet food, however we will ask. Yes NoPlease Confirm the Type of Animal (e.g., cat or dog) and The Size of the Animal (e.g. small, medium or large).*PLEASE BE AWARE - We cannot guarantee that the food bank will be able to provide pet food, however we will ask.Does anyone in your household have any allergies or dietary restrictions (e.g. vegetarian)?*If a Member of Your Household (e.g., an infant) Requires Formula/Baby Milk, Please confirm the Name and Type of Formula Required.PLEASE BE AWARE - We cannot guarantee that the food bank will be able to provide Formula, if they can, we cannot guarantee it will be the preferred type, however we will ask.What cooking facilities do you have?* Oven Hob Microwave Kettle None of the AboveDo You Need Toiletries?* Yes NoDo You Need Nappies? Please Confirm The Size of Nappies You Need*PLEASE BE AWARE - We cannot guarantee that the food bank will be able to provide nappies, however we will ask.Do You Have Enough Food For Tonight?* Yes NoI/We Need Help to Pay Household Energy*Household energy is Gas, Electric, Oil and Solid fuelsPlease Select...Yes: I have pre-payment metersYes: I don’t have pre-payment metersNoPlease Provide the Name of Your Energy Provider*Please Provide the Account Numbers for Your Gas and Electricity AccountsI/We Need Help to Pay for Other Household Essentials*Other household essentials maybe things like Bed(s), Mattress, Bedding, Counter top cooker/hob, Microwave with grill, Fridge. Crockery, Saucepans etc. - If you require more than 1 item please choose "Something else" and explain below, We will discuss this with you after we have received your application.Please Select...Bed/Mattress/BeddingCounter top cooker/hob or Microwave with grillFridgeCrockery/SaucepansSomething Else (please explain below)NoPlease Choose* Microwave with Grill Table-Top Oven with HobPlease Specify What You Would Like Help With*Please appreciate we have limited items that we can help with, we will discuss your needs with you individuallyPlease Tell Us The Main Reason for Your Emergency*Please Select...Increased bills and cost of livingLoss of benefitsLow incomeMy/Our income from earnings has droppedReduced hours at workRelationship BreakdownSomething elsePlease Explain What Else*Evidence to support your application.... If your application is only for food, evidence may not be required.It is very important to provide us with the evidence we have asked for below. If you are unable to this it will delay your application as we will need to ask for it via post, via email or in person. We cannot make an award without the evidence. Evidence showing your address must show your current address please. Photographs or scans of paper based evidence, such as letters, should be dated within the last 6 months and must show your name and address please.Agreement* I understand I need to provide evidence to support my applicationUpload your Latest Bank Statement or Screen Shots of Online Banking Transactions*This must cover a full calendar month and also show your current balance. Screen shots of online banking must show your name as well as transactions. Please provide multiple screen shots if required. If you have more than one bank account please upload the latest bank statement for each account I can upload evidence of my Bank transactions I am unable to upload evidenceUpload* Drop files here or Select filesAccepted file types: jpg, pdf, png, Max. file size: 4 MB, Max. files: 5.Obtain Proof of Your Universal Credit - Online Journal 1. Login to your UC journal 2. Go to "Payments" 3. Select the latest payment 4. Either screen shot or choose to print the statement. Make sure any screen shot includes where it shows your name and addressObtain Proof of You Universal Credit - Telephone Claim Please photograph your latest UC payment statement. Make sure the photograph includes your name and address as well as the paymentUpload Proof of Your Universal Credit + Other Benefits* I can upload my Universal Credit Payment Details I am unable to upload this evidenceUpload* Drop files here or Select filesAccepted file types: jpg, pdf, png, Max. file size: 4 MB, Max. files: 5.Upload Proof of Your ID and Somerset Address*Please provide a photograph or scanned image of official documents proving your ID and/or address. For example, a passport, driver's license, council tax bill, utility bill, bank statement or letter from DWP I can upload evidence of my ID and Address I am unable to upload this evidenceUpload* Drop files here or Select filesAccepted file types: jpg, pdf, png, Max. file size: 4 MB, Max. files: 5.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 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 Somerset County 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 Local Assistance Scheme by making a false declaration or providing false evidence I may have committed an offence under the Theft Act 1968. I confirm.CommentsThis field is for validation purposes and should be left unchanged.
