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Cymraeg

Welfare Support Request

1Your Details 2Welfare Support Request PPrivacy Policy

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Your Details

Forename

Surname

Phone Number

Email Address

Remember Me

Address

House Number / Name

Post code

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Welfare Support Request

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Date of birth (dd/mm/yyyy)

NI Number

Other household members:

0 1 2 3 4 5 More Than 5

Other Member 1:

Other Member 1 DOB:

Other Member 1 NI No:

Other Member 1 Relationship To Applicant:

Other Member 2:

Other Member 2 DOB:

Other Member 2 NI No:

Other Member 2 Relationship To Applicant:

Other Member 3:

Other Member 3 DOB:

Other Member 3 NI No:

Other Member 3 Relationship To Applicant:

Other Member 4:

Other Member 4 DOB:

Other Member 4 NI No:

Other Member 4 Relationship To Applicant:

Other Member 5:

Other Member 5 DOB:

Other Member 5 NI No:

Other Member 5 Relationship To Applicant:

Other Household Members Details:

Please select property type

Council Private Housing Association Owner Occupier

Number of bedrooms

Landlord name and address

Please list name, gender and age of all other household members

Income Details

Universal Credit?

Yes No

Amount of Universal Credit

Date of Universal Credit claim

ESA/IS/JSA

Yes No

Amount of ESA/IS/JSA

Date of ESA/IS/JSA claim

Tax Credits

Yes No

Amount of Tax Credits

Date of Tax Credits claim

Child Benefit

Yes No

Amount of Child Benefit

Date of Child Benefit claim

Earned Income

Yes No

Amount of Earned Income

Date of Earned Income claim

Other 1

Yes No

Please specify 1

Amount of Other benefit 1

Date of Other Benefit claim 1

Other 2

Yes No

Please specify 2

Amount of Other benefit 2

Date of Other Benefit claim 2

Other 3

Yes No

Please specify 3

Amount of Other benefit 3

Date of Other Benefit claim 3

Support Arrangements

Please confirm any current support arrangements:

Citizens Advice

Yes No

Shelter

Yes No

Local Authority Supporting People

Yes No

Social Services - Adult and Children

Yes No

Accommodation Support

Yes No

Other Support

Yes No

Please specify other support

Details of Customer's Support needs:

Please select support:

DHP MGPL/APA Budgeting Welsh Water reduction application DAF Other

Please specify other support need

Please also provide a detailed explanation of support needs below

Signatures

Customer name for agreement

Date customer signed agreement

Referee name for agreement

Date referee signed agreement

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Privacy Policy

Your data will be processed by Flintshire County Council only for the specific purposes of providing you with welfare support. The processing of your personal data is necessary as part of our public task under the Welfare Reform Act 2016. Your special category personal data is processed for reasons of substantial public interest under the Welfare Reform Act 2016. Flintshire County Council may share your data with other organisations relevant to providing welfare support e.g. Citizens Advice, Discretionary Assistance Fund and also with Flintshire County Council’s internal departments e.g. Supporting People, Housing, Accommodation Support in order to provide appropriate welfare support.

Flintshire County Council will retain your information for the current financial year plus 4 years from the date you no longer require our support.

If you feel that Flintshire County Council has mishandled your personal data at any time you can make a complaint to the Information Commissioner's Office by visiting their website or by calling their helpline on 0303 123 1113.

For further information about how Flintshire County Council processes personal data and your rights please see our privacy notice on our website - privacy notice