Date
Your Ref
Our Ref
Enquiries to
Direct Line
E-mail
DX
28 July 2017
SP/DK/SC Consent form
SP Team
Tel: (01204) 335313
[email protected]
716620. Bolton 10
SUPPORTING PEOPLE TEAM
Le Mans Crescent
Bolton
BL1 1SA
Tel:
01204 335313
Fax:
01204 337175
Minicom: 01204 335911
Dear Sir/Madam,
RE: SUPPORTING PEOPLE CONSENT FORM
From April 1st 2003, Support Services are being paid for by Bolton Metropolitan Borough Council
through Supporting People, a government programme for vulnerable people providing services
aimed to support independence whilst living in their own home.
In order to establish whether you are entitled to financial help towards your support services, it is necessary to share
personal information between relevant Bolton MBC Departments. If you are in agreement with the above, please
complete the consent form below return it to the address above.
If you have any queries about this consent form, please contact the Supporting People Team on the above number.
Thank You
CONSENT FORM FOR SUPPORTING PEOPLE SUBSIDY
Please tick one of the three boxes below
I am receiving Housing Benefit
I have applied for Housing Benefit
I intend to apply for
Housing Benefit
I give my permission for information in relation to my Housing Benefit and/or any support I receive under
Supporting People for any welfare service that I receive from a Service Provider to be shared between
the following parties:
 Bolton MBC
 Department of Work and Pensions
 My Supporting People Service Provider
 Bolton At Home
The type of information that may need to be shared will include the following:
 my Date of Birth;
 my National Insurance Number, whether or not I am in receipt of Housing Benefit;
 the date from which my Housing Benefit begins to be paid and the date on which it ceases to
be paid
 the amount of support charge I am required to pay by my Supporting People Service Provider
 and the Support Services that I am receiving.
Please tick the following box, if you are in agreement with the above:
Name:
Address:
Telephone Number:
National Insurance Number:
Name of Support Service:
Date Support Service started:
Signature:
Date:
Revised May’08