Local Assistance Scheme

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Verification

Are you aged 16 or over and a resident of Doncaster, or have you been placed in temporary accommodation outside Doncaster, by the City of Doncaster Council?

Are you receiving one of the following benefits:

Income Support
Employment Support Allowance (Income Related)
Job Seekers Allowance (Income Based)
Pension Credit (Guaranteed Credit)
Universal Credit with no deduction for earnings from your award

Title

Forename

Surname

Date of birth

Please provide your National Insurance number.
Please use capital letters eg AA123456A

Address of applicant

House number or name

Street

Locality

Town or city

Postcode

Contact details

Mobile number

Email (where we can send notifications about your application)

Is this application to support a move from care, hospital, prison, supported living or other organisation, or to support a move following a period of homelessness, after living in temporary, unsettled or unsuitable accommodation or fleeing violence?

Please give details

Have you experienced a crisis or sudden emergency which has resulted in your need for the items you are applying for?
Please note the Local Assistance Scheme cannot help with ongoing financial/budgeting issues or where a replacement item is required due to general use or wear and tear

Please give details

Are you applying for household items that are required to substantially improve your living conditions?

Is your application supported by a support worker, support organisation, charity, health professional or other body?

Full name of person supporting you

Name of organisation supporting you

Contact number

Email address

Do you have a partner who lives with you?

Forename of partner

Surname of partner

Date of birth of partner

National Insurance number of partner

Do you have any children who live with you and you claim child benefit for?

How many?

ChildFull nameDate of birth

Does anyone else live with you?

How many?

PersonFull nameDate of birthRelationship

Food

Are you applying for help with food?

Please select which voucher would you like

Energy

Are you applying for help with energy costs?

Who is your energy provider?

Do you have a smart meter?

If we make an award for energy costs, we may need to make a payment direct to your bank account. Please provide your bank details.

Name of account holder

Bank sort code (6 digits)

Bank or Building society account number (8 digits)

Household items

Are you applying for household items?

Item list

This is the list available today, you may not receive everything you request.

Description

Number

Fridge Freezer 60/40 50cm

Under Counter Freezer 50cm

Washing Machine 7kg 1200rpm Spin

Clothing Voucher

3 Piece Pot and Frying Pan Set

4 Mug Set

4 Place Crockery Set

4 Place Cutlery Set

5 Piece Utensil Set

Cot Fitted Sheet

Cot Mattress Hypo Allergenic

Double Bed Base + Mattress Breathable

Double Duvet Cover

Double Duvet

Double Fitted Sheet

Double Mattress Breathable

Fridge With Ice Box 85 x 55 x 60

Microwave 800W

Pillow

Pillowcase

Single Bed Base

Single Bed Base + Mattress W90 x L190

Electric Cooker Single Cavity 50cm

Single Duvet Cover

Single Duvet

Single Fitted Sheet

Single Mattress W90 x L190

Stairgate

Normally if you are a single person we will award a single bed. If this is not suitable and you require a double, please tell us why.

Has anyone helped you to make this application?

Can we contact this person about your application if we need to?

Full name

Contact number

Please provide any other information in support of your application

Declaration

The City of Doncaster Council may make enquiries about the information needed to support the application and to prevent fraud. If you receive an award under the Local Assistance Scheme by providing incorrect details or not giving us full details or providing false information you could be prosecuted. Awards from the Local Assistance Scheme are given as a grant, this means you will not be asked to repay the money to us. However, the Council, acting at its sole discretion, may require you to repay an amount equal to the value of any goods provided to you, in the event that you sell or dispose of the goods within 6 months of receipt. This declaration is legally binding. Please read all the points carefully and make sure you understand them before submitting your application.

I declare that the information I have given on this form is correct and complete.
I understand that if I knowingly give information that is incorrect or incomplete, I may be liable to prosecution or other action.
I understand that I must promptly tell the City of Doncaster Council of any further information which may affect the outcome of my application which I become aware of after it has been made.
I understand that the City of Doncaster Council may check the information I have given with other sources.
l understand the City of Doncaster Council may use any information I have provided in connection with this and any other claim for Social Security benefits that I have made or may make.
l understand the City of Doncaster Council may share information with other government organisations, if the law allows this.
I understand the City of Doncaster Council may use any information I have provided to identify other grants that may be available to me.
I understand that I must tell the City of Doncaster Council straightaway if I have a change of circumstances which may affect my application. This is my application for an award from the City of Doncaster Council Local Assistance Scheme.

I understand

Privacy Notice

This application and all documents related to this application will be treated in line with the Data Protection Act 1998.

I understand that the Council will check the information I have given with other information they hold about me and with the Department for Work and Pensions’ information. I also understand that the Council may check other records held by the Council and St Leger Homes to confirm that I have not received assistance from other schemes for the same purpose. If my application is successful, I understand that the Council will pass my name, address, email address and phone number to Family Fund Trading Ltd (FFTL) who arrange awards on behalf of the City of Doncaster Council. I also understand that FFTL will pass my contact details to the supplier of the goods and services I have been awarded. The City of Doncaster Council will not provide any further information about my application to FFTL or to any other person or organisation unless required by law.

I understand

You are not eligible to make an application to the Local Assistance Scheme. The eligibility criteria is located here including what to do if you disagree with this decision.