HSF Form

Before applying please note the following:

The Household Support Fund is funded by the Department for Work and Pensions. The fund is designed to provide short-term financial support to households who are struggling to afford household essentials. The fund is being distributed by Citizens Advice Surrey Heath on behalf of Surrey Heath Borough Council.
Awards are a one-off payment, payable in supermarket vouchers. Further applications from the same household will not be accepted
All applications must be supported by proof of ID, address and evidence of your benefit / income. You can either attach these to the confirmation email you should receive on submission of this form or bring/send them to our office

Before proceeding, please confirm that you are a resident of Surrey Heath This scheme is for Surrey Heath residents only, if you do not live in Surrey Heath you should contact your local authority

Please fill out the following information:

First Name *	Surname *

Address Line 1 *
Address Line 2
Postcode *
Ward *
Contact Telephone Number *
Email Address * (Please enter "n@a" if you do not use email)
Date of Birth *

Please tell us the main reason for needing support from the Household Support Fund*

ENERGY - Are you struggling with energy costs?*

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

Yes
No
If yes, have you had to use emergency credit in the last 3 months?
Yes
No

Are you in debt to your energy company?

FOOD - are you struggling with food bills?*

Yes
No
If so, which of the following apply to you (please tick all that apply)

Have skipped meals
Have used a foodbank or free food stall in the last 6 months
Have relied on help from friends or family
Have adjusted shopping habits to cut back

Are you struggling with other household essential costs?

Yes
No
If yes, please give details

Please indicate how you would like to receive your voucher*

Email (you will recieve a code redeemable at your choice of seven supermarkets)
Collection from our office

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*

Please enter the number of occupants who have a disability*

Please indicate which of the following benefits you receive*

Do you, or anyone you live with, having savings

If yes, how much?

Any additional information you would like considered:

I declare that the information I have given on this form is complete and correct to the best of my knowledge. *
I consent to the information I have provided being processed by Citizens Advice Surrey Heath in accordance with the General Data Protection Regulation and Data Protection Act 2018. Please refer to our online Privacy Policy at www.citizensadvicesurreyheath.org.uk for more information on how your personal data will be processed. *
I understand that applications are subject to approval, decisions are final and that there is no appeals procedure.*
I understand that Citizens Advice may need to contact me to obtain additional information. *
I am happy for Citizens Advice Surrey Heath to contact me for feedback about their service.

Citizens Advice Surrey Heath is a company limited by guarantee, registered in England and Wales. Company registration No: 6058583; Charity Registration No: 1118181

Household Support Fund - Summer 2024