Covid-19 Test and Trace Support Payments

Applicant details
Name*
Title First name Last name
Date of Birth*

Day
Month
Year
Contact telephone number*
Email*
Enter Email Confirm Email
Address*
Address 1 Address 2 Town Post code

Application information
Who are you completing this application for?*
- Yourself
- On behalf of someone else
Name of applicant*
Have you been contacted by NHS Test and Trace?*
- Yes
- No

Please provide your 8 digit CTAS ID. Do not leave any gaps when entering your CTAS ID.*
Please provide the start date of your isolation period, for example, 28/09/2020. Please note, you will only be eligible for this scheme if your isolation period started on or after 28 September 2020.*
DD slash MM slash YYYY

To select month click on left dropdown arrow and to select year click on right dropdown arrow in the calendar above
Please provide the end date of your isolation period, for example 12/10/2020*
DD slash MM slash YYYY

To select month click on left dropdown arrow and to select year click on right dropdown arrow in the calendar above

Employment details
Are you*
- Employed
- Self-employed
- Neither
What is the nature of your self-employment
What is your company name if applicable

Employer's name*
Employer's address*
Address 1 Address 2 Town Post code
Employer contact telephone number
What is the nature of your job?*
Are you able to work from home during your isolation period?*
- Yes
- No
Please upload proof of your self-employment status
Drop files here or

Accepted file types: jpg, gif, png, pdf, txt, doc, , Max. file size: 32 MB.

Will you have a reduction in earned income due to being told to self-isolate?*
- Yes
- No

Benefits details
Which of the following do you or any partner you may have receive?*
- Universal Credit
- Working Tax Credit
- Jobseekers Allowance
- Income Support
- Employment and Support Allowance
- Housing Benefit
- Pension Credit
- None of these - You do not meet the criteria for this scheme,if you want to be considered for a Discretionary payment please complete the remainder of the form and provide the requested proof.
National Insurance Number*

You will find this on your National Insurance card, benefit letter, payslip or P60. For example, QQ123456C. Do not leave any gaps when entering your NI number.
Employed discretionary claimants only
The Discretionary Test and Trace payment scheme is Government funded with a capped amount of funding that will shortly be used, this means that you may not be entitled to a discretionary payment due to there being no funds available.
If this is the case, and the Government increases funding for the Discretionary Test and Trace payment scheme, then the scheme will reopen and your claim will then be considered for payment, which may involve contacting you for further information to support your claim.
Updates on the scheme will be made on the Hyndburn Borough Council website if further funding is made available.
You have stated that you cannot work from home, please tell us why and provide proof from your employer.*
Please can you confirm your and, if you have one, your resident partner's annual income prior to being told to self-isolate.*
You have stated that you will have a reduction in your income due to self-isolating Please provide proof, and confirm how much the reduction will be and provide confirmation from your employer that your income will be reduce*
Self-employed discretionary claimants only
You have stated that you cannot work from home, please tell us why.*
Please can you confirm your and, if you have one, your resident partner's annual income prior to being told to self-isolate and provide a basic statement detailing your last three months self-employed income.*
You have stated that you will have a reduction in your income due to self-isolating please confirm how much the reduction will be for your period of self-isolation*
Bank details
Please provide the following details of your bank account that you wish the payment to go into.
Bank or Building Society account details
Name on the account*
Sort code*
Account number*

Must be between 6 and 8 digits long
Building Society roll number (if you have one)

You can find this on your card, statement or passbook.
Please upload your evidence documents here
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

Declaration*
I confirm that the information on my application form is true and correct and I understand that if I have given false information or incorrect details you may take legal action against me.

I agree to self-isolate for the required period and understand that if I fail to do so, I will be required to pay the Test and Trace Support Payment back to the Council.

The Council relies on your consent to access your records contained in the NHS Test and Trace data system, known as Data System (CTAS) for the purpose of confirming your eligibility for this scheme of payment. You can find more information on CTAS via the Privacy Notice.

You can withdraw your consent at any time by contacting the Council on 01254 388111. Please be aware if you do withdraw your consent, you will no longer be entitled to the payment under this scheme and will have to repay any support payment you have received.
- The council will also share your information if we have a legal duty to do so, with other organisations e.g. Her Majesty's Revenue and Customs or the Department of Health and Social Care
- The council will use your information in line with the GDPR act 2018. We have a duty to protect public funds and we may use the information you have given us or share it with other organisations to prevent and detect fraud.
Do you agree with the above declaration?
- Yes
- No

Covid-19 Test and Trace Support Payments

BRCC - COVID 19 - Test and Trace Support Payments (3)

Step 1 of 10

Applicant details

Application information

Employment details

Benefits details

Employed discretionary claimants only

Self-employed discretionary claimants only

Bank details

Bank or Building Society account details