Crisis and hardship grants request form

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Current Your details
Your income and expenditure
Complete

*Please give us as much information as possible and we will attempt to get back to you as soon as we can. Please ensure all mandatory questions marked with * are completed. If you are concerned about paying your rent, please contact your income officer to discuss how they can help. We can only support LiveWest customers who cannot access support to meet their needs through other routes and will expect customers to show what government or community support they have already accessed. These grants are available to LiveWest customers only, to cover emergency costs for food or energy. All grant applications will be assessed on a case by case basis and submission does not guarantee a grant will be awarded.

*Please tick this box to confirm that you understand the information above and would like to apply for a grant.

*Grants are only available for existing LiveWest customers. Please tick this box to confirm that you are an existing LiveWest customer

First name

Last name

Address

Address 2

City/Town

ZIP/Postal Code

*Local authority

*Telephone number

*Email address

Name of LiveWest colleague supporting you with this application (if relevant)

*I would like support with

food

energy costs

*Provide details of your situation and why you need support with food and/or energy costs.

*Please provide details of how many adults and children are in your household.

*I have previously accessed support through the LiveWest Tenancy Sustainment team

Yes

*I have previously received a LiveWest grant

Yes

Please tick any of the following that apply to you:

There is one or more children under 5 years of age living in my home

I am over 70 years of age or retired

I pay my rent through Housing Benefit

I currently receive Universal Credit

I am, my household is in receipt of a disability benefit and/or DLA or PIP

I have savings

Have you recently experienced any of the following:

a change in financial circumstances

loss of employment, reduction in working hours

expericned a delay in receiving a new benefit claim

change to an existing benefit claim

are in debt or financial concerns

other

*We normally only offer grant support to customers who do not have historic rent arrears. We will check our records to verify this information. Do you currently have rent arrears?

Yes

If yes, please explain how much and how this is being managed?

*Have you accessed or applied for funding from the government, local authority or other organisations and charities?

Yes

If yes, please provide details of this funding.

Internal Comments

Sign above

*How did you hear about our grants?

LiveWest website

Word of mouth

A LiveWest collegue

A LiveWest colleague

External organisations or agencies

*Please provide us with the dates of your next wages and/or benefit payments.

*If your application is successful please tick to confirm that you agree for LiveWest to share your details with a 3rd party for the processing of payment or vouchers.

Support needs and ethnicity

Are you happy for us to update your records with the details you provide?

Yes

Please select your ethnicity