Household Support Fund Form Published by: Susan Workman, on: 4 February 2025 Household Support Fund Form Apply for Household Support Fund Name(Required) First Last Address(Required) Street Address Address Line 2 Town Postcode Phone(Required)Email(Required) Date of Birth(Required) DD slash MM slash YYYY Age(Required)Ethnicity(Required)How did you hear about the Household Support Fund (click all that apply):(Required) Referral Friend Family Website Leaflet Social Media Word of Mouth Do you have a disability?(Required) Yes No Household Composition - select all that apply(Required) Household with Children Household with Pensioner Household with Unpaid Carer Household with Care Leaver Household with disabilty None of the above How many people living in the household?(Required)How many children under the age of 18 are living in the household (Required)(Required)Have you applied to the Household Support Fund previously?(Required) Yes No Were you successful? Yes No Have you received one or more of the following cost of living payments?(Required) None Cost of living payments Disability Cost of Living Payments Pensioner Cost of Living Payment What element of support are you applying for? (select most in need of)(Required) Food (Physical Voucher to be collected) Food (Electronic Voucher to be sent by email) Energy (Direct Debit Support) Energy (Pre-payment meter support) Small Appliances (Slow Cooker, Air fryer, Toaster, Kettle, Bedding etc.) Evidence - all applications will require bank statements. Please read the below for requirement of bank statements. • Bank statements for all accounts including saving accounts • Up to date, showing a full month’s worth of transactions • For all Adults within the household • Please make sure that all statements sent across in PDF format and no screenshots. If requesting energy support, please provide your energy bill showing the below• name and address • account number • proof of arrears / photo showing pre-payment meter arrears Please provide Evidence to support your application with the above-mentioned documents. You will be unable to submit the form without attaching evidence.(Required) Drop files here or Select files Max. file size: 64 MB. Please provide any other information in the box below:By applying to the Household Support Fund, you are agreeing to Hyndburn Borough Council sharing your details with Lancashire Women and Citizens Advice East Lancashire contact you to offer a range of additional support, schemes and services. Confirm(Required) Hereby, I agree Date DD slash MM slash YYYY SignatureX/TwitterThis field is for validation purposes and should be left unchanged.
