Welfare advice, debt and benefit support referral form

If you require advice or specialist support with Council debts you can complete this Form. A member of our Welfare & Debt Support team will contact you to help.

This Form may be completed by a resident or third party on behalf of a resident.

All fields are mandatory, however if you are unsure of any details please input ‘unknown’ in the relevant field.

Required fields are marked as *

Are you filling this form for yourself or is this a 3rd party referral?

Resident
3rd party referral

Resident

Name *

Address *

Postcode *

Date of birth *

Day Month Year

National Insurance number *

Phone Number *

Email address *

Details of the request * Please state the information, advice or help you need

Tell us about people who live with you * We will need to know their Name, Date of birth and relationship to you.

Tell us about your Income * Please include the type of income, amount received and how often.

Do you owe money to the Council? * Council Tax, Council Tax Support or Housing Benefit Overpayments, Rent arrears, Adult Social Care arrears etc

Any other relevant information that you want to share

Terms and conditions *

By submitting this form you agree to our privacy policy and terms of use.

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