MEDWAY LWP - REFERRAL FORM
Name
Organisation
Contact Number
DETAILS OF PERSON MAKING REFERRAL
Job Title
Email
Date
PARTNER’S DETAILS
Last Name:
First Name(s):
Date of Birth:
Tel Contact No.:
N.I.N.O
Prev Address:
(Incl. Postcode)
HOUSEHOLD AND CARING RESPONSIBILITIES:
Couple:

Single Male: 
Single Female: 
Lone Parent:

Not a Lone Parent:

APPLICANT DETAILS
Last Name:
First Name(s):
Date of Birth:
Tel Contact No.:
N.I.N.O
Address:
(Incl. Postcode)
Household Type:
Parental Status:
Do you have caring
responsibilities?
Yes:
 (detail below)
No:

(children or parents)
APPLICANT DETAILS
Dependent 1
PARTNER’S DETAILS
Dependent 1
(full name , DOB and
age)
(full name , DOB and age)
Dependent 2
Dependent 2
(full name , DOB and
age)
(full name , DOB and age)
Dependent 3
Dependent 3
(full name , DOB and
age)
(full name , DOB and age)
Dependent 4
Dependent 4
(full name , DOB and
age)
(full name , DOB and age)
Dependent 5
Dependent 5
(full name , DOB and
age)
(full name , DOB and age)
Dependent 6
Dependent 6
(full name , DOB and
age)
(full name , DOB and age)
Why does applicant require support from the LWP Scheme?
(Present circumstances which led to this crisis or emergency situation).
What does the applicant require from this Scheme for this situation and by when?
Is the applicant in receipt of any benefits or waiting to hear about any benefits?
YES

NO 
Details if yes and evidence/last date of payment:
Does applicant have any savings/income which could contribute YES

NO
Details if yes and evidence:
.
Details of any previous applications for support from this applicant (including any
unsuccessful applicants)
What steps are being taken for the longer term solution?
How long have you lived in the Medway area/what connection do you have with the
Medway area?
What will happen if you don’t receive this support?

Income Received
TYPE OF INCOME
APPLICANT
Weekly
Monthly
APPLICANTS PARTNER
Weekly
Monthly
Wages/salary
Statutory sick pay
Income Support
Job seekers allowance
income/Contributions based
please specify
Housing Benefit
Employment & Support AllowanceWork /Support related Please
specify
Universal Credit
Incapacity Benefit
Disability Living AllowanceCare/Mobility please specify
Personal Independence Payment –
care/mobility please specify
Attendance Allowance
Severe Disablement Allowance
Carers Allowance
Statutory Maternity/Paternity Pay
Maternity Allowance
Industrial Injuries Allowance
Child Benefit
Maintenance
Child Tax Credit/Working Tax Credit
State Retirement Pension
Pension credit
Savings Credit
Occupational Pension
Armed Forces Pension
Insurance Annuity
War Widows Pension
Bereavement Allowance
Savings
Other – please specify
Total
£
£
£
Expenditure/Outgoings
TYPE OF EXPENDITURE
APPLICANT
Weekly
Monthly
APPLICANTS PARTNER
Weekly
Monthly
Mortgage Payments
RENT
Council Tax
Water rates
Ground Rent/Service Charge
Building/Contents Insurance
Life Insurance
Private Pension
Gas
Electricity
Other Fuel
Food shopping
TV Rental/Licence
Maintenance payments
Travel Expenses temp job
School Meals
Clothing
Telephone
Prescriptions
Childminder/nursery fees
Car insurance/MOT etc
Loans
Credit cards
Fines
Other- Please specify
Total
£
£
£
£
DECLARATION
I declare the information provided and contained in this application is true and
complete and has been made with the authority of the applicant.
I can confirm that I am in receipt of benefits and am not currently subject to any
sanction or investigation for fraud of misuse of benefits and I have provided a letter
or statement dated in the past month upon this application.
I am aware that I can only apply twice to the Local Welfare Provision scheme in any
12 month period.
I authorise the LWP Scheme Provider and their employees to share this information
with its partners Medway Council and Job Centre Plus and other government
bodies/organisations in order to enquire or gather evidence to fully determine
entitlement to receive assistance from the Local Welfare Provision Scheme.
The applicant understands that all my personal information is provided in confidence
and will be held securely.
The applicant is aware that all information will be checked and verified and false
information may exclude the applicant from support now and in the future. Any
instances of fraud will be reported to Medway Council and the Department of Work
and Pensions and sanctions may be applied.
PRINT APPLICANT’S NAME:
APPLICANT’S SIGNATURE:
DATE:
EQUALITY & DIVERSITY MONITORING FORM
The information that you provide on this form will be used for monitoring and will not be used for any
other purpose or stored SECURELY. Information will be used in aggregate form only and where there
are less 3 people providing a response this will not be reported.
APPLICANT AGE
Please choose one option
only.
Under 18
25-34
45-54
65-79








18-24
35-44
55-64
80 & over
DISABILITY STATUS
Do you consider yourself to be a disabled person i.e. may experience discrimination on grounds of
impairment or long-term health condition? Please choose one option only.
Yes

No

I prefer not to answer this question
If yes, please choose all the relevant options.

Physical impairment

Mental health condition

Memory impairment
Long-standing illness or health condition 
Any other impairment  - please specify below
Sensory impairment
Learning disability / difficulty
Visibly different



I prefer not to answer this question 
GENDER
Please tick one box only
Male 
Female 
I prefer not to answer this question 
MARITAL / CIVIL PARTNERSHIP STATUS
Please choose one option only (the one that best describes your status).
Separated, but still
Married or in a
Divorced or dissolved
legally married or in
civil partnership

civil partnership

a civil partnership
Surviving partner from
Widow or widower

Living with someone
a civil partnership

Single



I prefer not to answer this question 
RELIGION AND BELIEF
Do you belong to a particular religion or hold a particular belief? Please choose one option only.
Yes

No

If Yes, which option best describes your religion or belief? Please choose one option only.
Agnostic

Hindu

Pagan

Atheism

Humanist

Sikh

Buddhist

Jewish

Christianity (all

Muslim

denominations)
Other religion/belief  - please specify below
I prefer not to answer this question 

RACE AND ETHNICITY
Please choose one option only (the one that best describes your racial/ethnic origin).

White
British

Irish
 - please specify below
Any other White background
White & Black Caribbean
White & Asian
Any other Multi-Ethnic
background


White & Black African

- please specify below
Asian or Asian British
Indian
Bangladeshi
Any other Asian background



Pakistani
Chinese
- please specify below


Black or Black British
Caribbean
Any other Black background


African
- please specify below

Other
Arab
Gypsy/Romany/Traveller of Irish
Heritage
Any other Ethnic background

Multi-Ethnic



- please specify below
I prefer not to answer this question 
SEXUAL ORIENTATION
Please choose one option only (the one that best describes your sexuality).
Bisexual

Gay woman/Lesbian

Gay man

Heterosexual/Straight

Other (please specify below) 
I prefer not to answer this question 
Protecting your personal information
The LWP Scheme Provider (the Data Controller) will keep the information provided above as
confidential. Access to, retention and disposal of this information will be strictly in accordance with
data protection requirements. It will be used solely to ensure that The LWP Scheme Provider meets
its obligations under equality legislation. Individuals will not be identifiable in any reporting.