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Your details
Your income and expenditure
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*Please give us as much information as possible and we will attempt to get back to you as soon as we can. Please ensure all mandatory questions marked with * are completed. If you are concerned about paying your rent, please contact your income officer to discuss how they can help. We can only support LiveWest customers who cannot access support to meet their needs through other routes and will expect customers to show what government or community support they have already accessed. These grants are available to LiveWest customers only, to cover emergency costs for food or energy. All grant applications will be assessed on a case by case basis and submission does not guarantee a grant will be awarded.
*Please tick this box to confirm that you understand the information above and would like to apply for a grant.
*Grants are only available for existing LiveWest customers. Please tick this box to confirm that you are an existing LiveWest customer
*Name
First name
Last name
*Customer address
Address
Address 2
City/Town
ZIP/Postal Code
*Local authority
- Select -
Gloucestershire
South Gloucestershire
Bristol
Bath and North East Somerset
South Somerset
Mendip
Taunton and West Somerset
Sedgemoor
Devon
Cornwall
Dorset Council
North Somerset
Plymouth City Council
Torbay
Exeter City Council
*Telephone number
*Email address
Name of LiveWest colleague supporting you with this application (if relevant)
*I would like support with
food
energy costs
*Provide details of your situation and why you need support with food and/or energy costs.
*Please provide details of how many adults and children are in your household.
*I have previously accessed support through the LiveWest Tenancy Sustainment team
Yes
No
*I have previously received a LiveWest grant
Yes
No
Please tick any of the following that apply to you:
There is one or more children under 5 years of age living in my home
I am over 70 years of age or retired
I pay my rent through Housing Benefit
I currently receive Universal Credit
I am, my household is in receipt of a disability benefit and/or DLA or PIP
I have savings
Have you recently experienced any of the following:
a change in financial circumstances
loss of employment, reduction in working hours
expericned a delay in receiving a new benefit claim
change to an existing benefit claim
are in debt or financial concerns
other
*We normally only offer grant support to customers who do not have historic rent arrears. We will check our records to verify this information. Do you currently have rent arrears?
Yes
No
If yes, please explain how much and how this is being managed?
*Have you accessed or applied for funding from the government, local authority or other organisations and charities?
Yes
No
If yes, please provide details of this funding.
Internal Comments
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*How did you hear about our grants?
LiveWest website
LiveWest Newsletter/letter/email
Word of mouth
Facebook/social media
A LiveWest collegue
A LiveWest colleague
External organisations or agencies
*Please provide us with the dates of your next wages and/or benefit payments.
*If your application is successful please tick to confirm that you agree for LiveWest to share your details with a 3rd party for the processing of payment or vouchers.
Support needs and ethnicity
Are you happy for us to update your records with the details you provide?
Yes
No
Please select your ethnicity
- Select -
White: British
White: Irish
White: Gypsy/Irish traveller
White: Other
Mixed/Mixed British: White & Asian
Mixed/Mixed British: White & Black Caribbean
Mixed/Mixed British: White & Black African
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Other
Black/Black British: Caribbean
Black/Black British: African
Black/Black British: Other
Other Ethnic Group: Arab
Other Ethnic Group: Other
Prefer not to say
Support Need information helps us adapt the services we provide, so you as our customers can access them in a safe, fair and equitable way. The list below shows a range of tasks that some customers may find more challenging due to a long-term disability or health condition (including mental health). Please tick all that apply (if you have no support needs or prefer not to say please tick the relevant box
Hearing or listening
Holding or grasping
Learning or understanding
Moving around
Reading
Remembering
Respiratory or breathing difficulties
Seeing
Speaking and talking
Thinking or feeling clearly
Writing
No support needs
Prefer not to say
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