Household Support Fund

Funding has been allocated via the Department of Work and Pensions to help families who are struggling financially in Epsom & Ewell.

Financial assistance is available for food, energy, water and other essentials. The fund is being distributed by Citizens Advice Epsom and Ewell on behalf of Epsom & Ewell Borough Council.

Before applying please note the following:

• Eligibility – you may be eligible for support if you are on benefits, live in a low income household or require crisis support (where the crisis would cause financial hardship)
• The support will be in the form of:
  • supermarket vouchers;
  • direct payments to energy/water suppliers;
  • top up for prepayment meters;
  • purchase of appliances and goods; or
  • direct payment for specific services.
• All applications must be supported by:
  • proof of ID;
  • proof of address;
  • evidence of your benefits / income; and
  • your latest bank statement

You can either attach these in response to the confirmation email you will receive on submission of your application or bring them into our office.

The scheme that we administer is for Epsom and Ewell residents only, if you do not live in Epsom and Ewell you should contact your own local authority for details of how they are distributing the fund.

Before proceeding, please confirm that you are a resident of Epsom and Ewell

Are you resident in the Borough of Epsom & Ewell? You cannot apply if your answer is "No" *

• Yes
• No

Name *

First

Last

Please also give the name of any spouse or partner that lives with you:

First

Last

Address Line 1 *

Address line 2

Postcode *

Contact phone number *

Email Address (Please enter n@a.com if you do not use email) *

Date of birth

Please tell us the main reason for needing support from the Household Support Fund *FoodEnergy and/or waterOther household essentialsSomething else

You selected "Something else" - can you tell us about it?

ENERGY - are you struggling with energy costs? *

• Yes
• No

Do you have a prepayment (top-up) meter?

• Yes
• No

If you have a prepayment meter, have you had to use emergency credit in the last 3 months?

• Yes
• No

WATER - Are you struggling with water bills? *

• Yes
• No

Are you in debt to your water company? *

• Yes
• No

FOOD - are you struggling with food bills? *

• Yes
• No

If so, which of the following apply to you (please select all that apply):Have skipped mealsHave skipped mealsHave used a foodbank or free food stall in the last 6 monthsHave relied on help from friends or familyHave adjusted shopping habits or cut back

OTHER Household Essentials- are you struggling with other household essential costs?

• Yes
• No

If so, please specify

If eligible, please indicate how you would like to receive a Supermarket voucher

• Electronic supermarket voucher (sent by email)
• Collection from our office - Physical supermarket voucher

We will do our best to accommodate a voucher for your choice of supermarket, please specify your preference

Please enter the total number of occupants living in the household *

Please enter the number of occupants under the age of 18 living in the household *

Please enter the number of occupants of pension age living in the household *

Are there any disabled people in your household? *

• Yes
• No

How many disabled people in your household are adults (aged 18 or over) ? *

How many disabled people in your household are under 18?? *

How many disabled people in your household are of pension age? *

Does anyone in the household receive a disability benefit? *

• Yes
• No

Please say which disability benefit(s) they receive. Select all that apply *Disability Living AllowanceDisability Living AllowancePersonal Independence PaymentAttendance Allowance

Please indicate which of the following benefits YOU receive. Select all options that apply *Carers AllowanceCarers AllowanceESAJSAIncome SupportPension CreditChild Tax CreditsWorking Tax CreditsHousing BenefitUniversal CreditOtherNone

If you selected "Other" benefits, please specify *

Do you have any other sources of income, apart from benefits? *

• Yes
• No

Please list your other source(s) of income and the amount(s) received per month: *

Do you, or anyone living with you, have any savings? *

• Yes
• No

If you answered "Yes" to savings, how much? *

Any additional information you would like to be considered. Why do you need help from the fund? *

Declaration *

• I declare that the information I have given on this form is complete and correct to the best of my knowledge. I understand that applications are subject to approval, decisions are final and that there is no appeals procedure.

Consent to process personal data *

• I consent to the information I have provided being processed by Citizens Advice Epsom and Ewell in accordance with the General Data Protection Regulation and Data Protection Act 2018. Please refer to our online Privacy Policy at https://www.caee.org.uk/ for more information on how your personal data will be processed

Consent to be contacted *

• I understand that Citizens Advice may need to contact me to obtain additional information

Are you happy for Citizens Advice Epsom and Ewell to contact you for feedback about their service?

• Yes
• No

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