Self-referral Form 1. 2. 3. Spam protection, skip this field Provide as much detail and proof of your finances as possible so we can process your application without delay. If you are suffering domestic abuse, you can tell us via this form. If you are in immediate danger, call 999. Full name (First, Last) Email Full address (with postcode) If you are homeless, or roughsleeping, please provide a contact point or hostel details. Phone number If you are homeless or roughsleeping, or do not have a phone, please provide a contact phone number. Date of birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Marital status Choose Single Married Divorced Widowed Living with someone Other How many people (including you) live in your home? If you are homeless or roughsleeping, please write 'HOMELESS' How many children under 18 do you have living with you? Religious Belief Muslim Christian Jewish Sikh Hindu Other None Rather not say Please let us know which religion you follow Are you or anyone in your household employed? Yes - full time Yes - part time No How much is your household income each week? Please upload proof of your households income weekly/monthly Choose file Uploading… (0%) Browse This can be your last 3 months of bank statements or pay slips This is invalid This file size is too big Delete Delete Delete Delete Delete 5 of 5 file limit remaining Do you or anyone in your household receive any State Benefits? Yes No Do you receive help from any other organisation, food bank, person, overseas? Yes No Please provide further information that may be useful to us Who provides help? How often - weekly, monthly? How much money do they provide? Do they provide food aid? How much is your rent/mortgage each week? To work out the WEEKLY amount, divide your monthly payment by 4 If you pay your own Council Tax, how much do you pay each week? If your Council Tax is paid by Universal Credit/Council Tax Benefit, please write that as your answer How much do you spend each week on gas and electric? Please give us an AVERAGE WEEKLY amount, we know sometimes it can be more and sometimes less How much do you spend on water rates each week? Do you pay for a TV Licence? Yes No On average, how much do you spend on WEEKLY travel expenses? (Include bus, tram, train, taxis) On average, what is your WEEKLY food bill? On average, how much do you spend on clothing/shoes per week? On average, what is your WEEKLY phone and/or internet bill? Please tell us about any other expenses you have. If no other expenses, write 'NONE'. We need to see proof of the expenditure you have told us about. Please upload your last 3 months bank statements, proof of rent/mortgage, travel tickets, phone/internet bill, gas/electric/water bills. (optional) Choose file Uploading… (0%) Browse If you have already uploaded your last 3 months bank statements in the previous section, you do not need to re-upload here. This is invalid This file size is too big Delete Delete Delete Delete Delete 5 of 5 file limit remaining Tell us about your current situation and any problems you need help with. Some examples are: domestic abuse, addiction, homelessness, roughsleeping, benefits sanctions, loss of job. If there are not any additional problems, write 'NONE' I declare that the information given is complete and accurate. I undertake to inform UKeff of any significant change in my financial circumstances as it occurs. I consent to UKeff sharing my details with other registered charities and organisations currently providing support during the Covid-19 Crisis Yes I / We consent to UKEFF holding our data and sharing with organisations that may be able to assist Yes No
