To see more about how we record and store your information please see the Council’s privacy notice. BRCC - COVID 19 - Test and Trace Support Payments (1) Step 1 of 10 10% This form should only be completed if you are the parent of or guardian of a child who is under 15 years old or a young person who is under 25 years old with an Education, Health Care Plan who has been told to self-isolate and you have to take time off to look after them. This form is not for applicants who have themselves been told to self-isolate. Please note that there is only one application allowed for each period of self-isolation for each child that has to self-isolate. Please read carefully before starting your online application for Test and Trace Support Payments. To be eligible for a Test and Trace Support Payment you must satisfy criteria that is set out in the application form. You will be asked to provide certain documents during the completion of the application form all of which will be verified prior to approval of your support payment. If you fail to provide the required evidence within 14 days of your application then your application for a test and trace support payment will not be processed. Please note that if you are a taxpayer then any Test and Trace Payment you may receive is taxable but it is not subject to National Insurance Contributions. Her Majesty's Revenue and Customs will automatically collect tax from your pay through your tax code, or if you are self-employed you should report the payment on your 20/21 Self-Assessment tax return.Applicant detailsName* Mr.Mrs.Miss.Ms.Dr.Prof.Rev. Title First name Last name Date of Birth* DD MM YYYY Contact telephone number*Email* Enter Email Confirm Email Address* Address 1 Address 2 Town Post code Child or Young Person's informationApplication informationYou may be entitled to financial support £500 if you meet all of the following eligibility criteria: You are the parent or guardian of a child who is under 15 years old or a young person who is under 25 years old with an Education, Health Care Plan who has been told to self-isolate and you have to take time off to look after them on or after 8th March 2021 2020; You are employed or self-employed; You cannot work from home and will lose income as a result; You are currently receiving at least one of the following benefits: Universal Credit, Working Tax Credit, Income-based Employment and Support Allowance, Income-based Jobseeker's Allowance, Income Support, Housing Benefit and/or Pension Credit. This application is for one person only and any further applications within the same household must be made by each individual. Please ensure that you have the information below available before starting the application: NI number; Your 8 digit test and trace ID number; Your most recent bank statement, proof of self-employment or wage slips. Are you the completing this form as the parent or guardian of a child or young person who has been told to self-isolate?*YesNo, I am completing the form on behalf of parent or guardian of a child or young person who has been told self-isolateIf completing the form on behalf of someone else, the following information must relate to that personName of applicant you are completing the form on behalf of*Has your child or young person been told to self-isolate by NHS Test and Trace or their educational or child care setting?*YesNo Please provide the following information about the child or young personYoung person or Child's full name:*Young person or Child's age:*Young person or Child's main address:*Young person or Child's education or care setting and year group:*Contact details for education or care setting (at least one of the following email address and/or phone number).*Do they have an Education, Health and Care Plan?YesNo Please provide your child or young person’s 8 digit CTAS ID if they have one. Do not leave any gaps when entering the CTAS ID.If your child or young person has been told to self-isolate by their education or childcare setting, please upload the communication that you have received about self-isolation at step 7 later on in the process. Please provide the start date of their isolation period, for example, 08/03/2021. Please note, you will only be eligible for this scheme if their isolation period started on or after 8th March 2021.* DD MM YYYY Employment detailsAre you*EmployedSelf-employedNeitherWhat is the nature of your self-employmentWhat is your company name if applicablePlease upload proof of your self-employment status Drop files here or Accepted file types: jpg, gif, png, pdf, txt, doc, . Employer's name*Employer's address* Address 1 Address 2 Town Post code Employer contact telephone numberWhat is the nature of your job?* Are you able to work from home during your isolation period?*YesNoWill you have a reduction in earned income due to being told to self-isolate?*YesNo Benefits detailsWhich of the following do you or any partner you may have receive?*Universal CreditWorking Tax CreditJobseekers AllowanceIncome SupportEmployment and Support AllowanceHousing BenefitPension CreditNone 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 onlyThe 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 onlyYou 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 detailsPlease provide the following details of your bank account that you wish the payment to go into.Bank or Building Society account detailsName on the account*Sort code*Account number*Must be between 6 and 8 digits longBuilding Society roll number (if you have one)You can find this on your card, statement or passbook.Please upload the following evidence to support your application: Proof of your employement status, e.g. recent wage slips or your most recent self-employed tax assessment Proof of the bank account detailed above, e.g. recent bank account statement that shows your name, the account number and sort code Communication from your child or young person’s education or childcare setting that states that they have to self-isolate A screenshot of the young person’s NHS COVID-19 App notification telling them to self-isolate evidence that the young person has an Education, Health and Care Plan The evidence documents should be uploaded one by one. If the requested proof is not uploaded, we will write to you asking for the proof to be provided. This will delay your application assessment. If you cannot upload the required documents, do not delay submitting your form. Please email the documents within 14 days to email@example.com and include the following text in the subject “TTSP supporting documents”Please upload your evidence documents here Drop files here or Accepted file types: jpg, gif, png, pdf. 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. 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? YesNoPlease read the above declaration and tick Yes to confirm your understanding. SORRY - You do not qualify for a Test and Trace Support Payment. If you wish to be considered for a Test and Trace Support Payment please submit your claim by clicking the button below. If the submit button is not clicked your application will not be submitted and any progress will be lost.