Home essential fund application form

Required hidden information

Record Type

ContactId

RecordId

Customer details

Council Tax account number (if known)

Full name

Address (including postcode)

Contact number

Email

Benefits and support

Please give details of your household income below, including the amounts you receive and how often. You may be asked to provide evidence to confirm details.

Enter details of all the capital/savings you currently have. Enter account details and balances of all accounts held.

Available support

Select the support you are applying for (select all that apply)

Boiler servicing to ensure boilers are as efficient as possible.Boiler replacement for items that are no longer suitable for useOil heating servicing and support for residents that use oil for fuelling their homeWhite goods provision. To supply replacement or new energy efficient items to households including cookers, fridges/freezers, washing machines/washer dryers and other items as appropriateBeds and mattresses to homes that do not have suitable bed provision

Boiler servicing

Why are you asking for help with your boiler service?

Boiler replacement

Why are you asking for help with your boiler replacement?

Oil heating and tune ups

Why are you asking for help with your oil heating and tune ups?

Declaration

Has someone helped you complete this form?

Yes

No

Full name

Contact telephone number

Email

Relationship to you

Confirmation

I do not have access to any funds that can be relied on to meet the need I am applying for.
I understand that the Council will pass on your information to partnered suppliers in some cases in order for the delivery, fitting and removal of items to be administered.
I understand that this scheme is discretionary and awards are not guaranteed.
I declare that all of the information I have given in this application form is entirely accurate and complete. I understand and accept that if I give any information that is inaccurate or incomplete, action may be taken against me (including by way of legal proceedings).
I agreed that the Council may check the information I have given on this application for with third parties (to the extent allowed by law).
I agreed that I must let the Council know immediately in writing (which may include notification online and / or by email) about any changes in my circumstances and those contained in the application form which might affect my award.
I agree that the Council may at its discretion share relevant data with third parties, including but not limited to government departments, local authorities and private-sector companies such as banks and organisations (that may lend me money), in each case to the extent allowed by law.
I agree that the Council will not be responsible for any inaccuracies I make in completing this application form.
I agree that the Council will use the information I have provided in this application form to assess my eligibility for support under this scheme.

I agree to all of the above and confirm that all details on this form are correct

Signature

Name

Date

Data usage

We will use the information you give in this form and any supporting evidence you send us to determine eligibility for this scheme.

By law, we may check information you have provided, or information provided about you by someone else, against other information we already have. We may also ask other agencies, organisations, local authorities or government departments to give us information they have about you. This is to:

make sure the information is accurate
prevent or detect crime, and
protect public funds

These third parties include other departments, organisations, government departments, local authorities and private sector companies such as banks and organisations that may lend you money.

View the councils full privacy policy

For further information on how we may share information with Kent County Council please see the KIN privacy notice