Date of Birth (required):

Do we have permission to call you on this phone number? (required): YesNo
Do we have permission to text you on this phone number? (required): YesNo
Do we have permission to leave a voicemail on this phone number? (required): YesNo

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The new local Crisis & Resilience Fund has new eligibility criteria and aims to support people facing an unexpected financial shock.

Financial shock refers to a specific event or change in circumstances that has suddenly created financial difficulty and immediate need. Examples may include:

• Sudden loss of employment or significant reduction in working hours

• Delays in benefit payments or changes to entitlement

• Relationship breakdown

• Domestic abuse resulting in emergency relocation

• Serious illness or injury affecting income

• Bereavement

We will request evidence of your circumstances to support an application to the fund which will include proof of income and bank statements. We will not be able to proceed with an application without this information.

Are you facing a financial shock? (required): YesNo

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What benefits are you or a member of your household already claiming? (required):

What is the problem with your benefits? (required):

Circumstance (i.e. reasons for being on/claiming benefit – not working, low income, disability, children, housing, etc.) (required):

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What are the goods or services and what is wrong with them? (required):

When did you first find the goods or work was faulty? (required):

Where and when did you buy the goods/services? (required):

How were the goods paid for & do you have a receipt/credit agreement? (required):

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Roughly how much money do you owe? (required):

Do you have any rent/mortgage arrears/council tax/outstanding fuel bills? (required):

Are the debts in your name/joint names? (required):

Any savings or assets (e.g. Car valued over £1000)? (required):

How much can you afford to pay each week? (required):

Do you have a current bank account? (required): YesNo

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Are you:
Employed? (required): YesNo

Self-employed? (required): YesNo

Are you a member of a trade union?
Please select...YesNoPrefer not to say

Are you still working? (required): YesNo

If not, were you dismissed, made redundant, walked out, suspended?

How long have you been employed? (required):

Name of employer? (required):

Do you have a written contract? (required): YesNo

What has happened? (required):

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Present situation and information or advice requested (required):

Are you in a relationship? (required): YesNoN/A

Are you living together? (required): YesNoN/A

Are any children involved? (required): YesNo

If so, what are their ages?

Are there any emergencies, e.g. domestic violence, have nowhere to stay? (required): Please select...YesNo

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Who is your current energy provider: (required):

Are you in debt with your current energy provider? (required): Please select...YesNo

Do you currently have electricity and gas available? (required): Please select...YesNo

What type of payment method are you using? (required): Please select...Direct DebitPay-paymentBank TransferOther

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Are you struggling with any household bills? (required): YesNo

Do you have a bank/Post Office account? (required): YesNo

Are you happy/confident searching for best deals i.e. energy/phones/insurance? (required): YesNo

Do you have any money issues preventing you from buying household essentials i.e. Food/energy/white goods? (required): YesNo

Are you confident with household budgeting? (required): YesNo

Details of this issue

Present situation and information or advice requested (required):

Details of this issue

Are you homeless, threatened with eviction or have to leave your home for another reason (e.g. domestic violence)? (required): YesNo

Is there an emergency, e.g. court dates, eviction notices, court warrants, threat of violence from somebody? (required): YesNo

If you have a tenancy:
Is it fixed term?YesNo
How long is the term?
Who is your landlord?
Do they live in the same property? (required): YesNo
Do you have any dependent children living with you? (required): YesNo

Universal Credit housing element or Housing Benefit:
Are you receiving it? (required): YesNo
or
Have you applied for it? (required): YesNo

What is the problem with your housing? (required):

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Is the enquiry about: (required): YouYour partnerOther person

What is nationality of you/partner/other person? (required):

Full details of immigration enquiry: (required):

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Can you briefly describe what you want help with? (required):

Please enter other other other other other problems here, not