Gloucestershire Welfare Reform Offer
Application Form
This paper form cannot be used to apply. Applications must be
via the “on-line form”
An award will only be paid where it will have a substantial and immediate effect in
resolving or improving an applicant’s circumstances and is appropriate for the
applicant’s circumstances.
Applications can be made for:
People in an emergency where there is a serious risk to their own or their family’s
health and safety
Applicants under exceptional financial pressure (i.e. who do not have the resources
to meet their own or their family’s immediate short term needs).
Anyone who needs help in setting up home in a Gloucestershire community:
o Having left institutional or residential care or supported housing (or about to
leave such care or support within the next six weeks).
o Who are eligible under Gloucestershire Reconnection Policy
A resident of Gloucestershire who, without an award, would otherwise need to go
into institutional or residential care
A resident of Gloucestershire who needs support in caring for someone
o Who has left institutional or residential care
Or
o Who, without care, would otherwise need to go into institutional or residential
care
Families under exceptional pressure
Applicants must meet the eligibility criteria:
Be resident in Gloucestershire
Be on Low Income
Be 16 years old or over
Be in one of the priority groups shown in part three of this document
You must complete all of the form and attach the relevant documents to prove
you are eligible for your application to be processed. It will speed up your
application if an agreed agency/service confirms your case for application.
Remember - awards are discretionary. Unfortunately some applications will be
unsuccessful
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What is Gloucestershire Local Welfare Offer?
One-off practical support or other forms of assistance for people who are eligible
The offer is discretionary
There is an emphasis on the use of recycled goods, food parcels and non-cash
awards
Individuals will only be eligible to receive one award in any 12 month period
How to Apply
The attached application form must be completed
After you have applied
If an application is successful, an award will be made within 24 hours to 10 days
depending on the critical nature of the situation
If an application is refused, individuals cannot re-apply for an award within 12 months
unless there has been a relevant and significant change in circumstances or substantial
and relevant information was not presented in the first application.
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Gloucestershire Welfare Reform Offer
Application Form
Tel: 0330 123 5550
Email: [email protected]
Part 1
About you
Address: XXXXXXXXXXXXXXXXXX
Are you 16 years old or older
No
Sorry, you cannot apply to this fund
Yes
Please go to the next question
No
Sorry, you cannot apply to this fund
Yes
Please complete the next section
No
Sorry, you cannot apply to this fund
Yes
Please complete the next section
Are you:
Resident in Gloucestershire
Or
Leaving residential or institutional care
to live in Gloucestershire
Or
In need of help to live independently in
Gloucestershire
Are you on low income?
Part 2
Help you are receiving
Do you have a:
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Social Worker
Case Worker
Support Worker
Probation Officer
If you have ticked one of the above, please fill in the details below:
Contact Name 1
Contact Name 2
Organisation Name 1
Organisation Name 2
Address 1
Address 2
Post Code
Post Code
Telephone Number 1
Telephone Number 2
Email
Email
To support your application, you can include any information or supporting letters from your
Social Worker, Support Worker, Case Worker, Probation Officer, Health Visitor, Home Carer,
CAB Adviser. They can also add information below:
Part 3
About your needs
The ‘Gloucestershire Local Welfare Reform Offer’ is a one-off discretionary award for
people
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g e are in the priority groups listed below and are experiencing the effects of a
critical situation. Please tick all the groups to which you belong. Please also tick all of
the benefits that you currently receive.
At risk of entering institutionalised care
At risk of significant harm or exploitation
Avoid an uncontrollable debt
Care leavers 16 to 18 years (up to 25 years old if in
education)
Ex-offenders/leaving YOI
Resettlement from custody for young people
Leaving accommodation based support services
Leaving residential care
Fleeing domestic abuse
Escaping hate crime/harassment
Person with terminal illness
Child in Need in the home
Child has child protection plan
History of homelessness
Runaways
Sleeping rough for long period
Living in poor accommodation including living in
temporary accommodation
Families where parent is misusing alcohol/drugs or
has mental health crisis
Pregnant women
Assessed by Gloucestershire County Council as
being eligible for support from Health and Social
care
Telecare user
Person with chronic illness
History of Mental illness / self-harming
History of substance or alcohol misuse and actively
seeking rehabilitation
Disability Living Allowance
Personal Independence Payments
Attendance Allowance
Pension Credit
Incapacity Benefit
Employment and Support Allowance
Industrial Injuries Disablement
Benefit
Statutory Sick Pay
Job Seekers Allowance
Child benefit
Child tax credit
Guardian’s Allowance
Carer’s Allowance
Income Support
Universal Credit
Housing Benefit
Are due to leave care within the next
six weeks and likely to get one of
the above benefits
Other – please specify
You should also provide evidence of your priority group, for example, a copy of your MATB1
maternity certificate, birth certificates of your children or correspondence from your doctor or
letter from for instance your support worker, housing providers etc.
If you are not in any of the priority groups, you cannot apply to this fund. Your support
agency can suggest other forms of support for which you may be eligible.
Part 4
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Your information
Title: Mr/Mrs/Miss/Other
Surname
All other names – in full
Address
Post code
Telephone number
Date of Birth
National Insurance Number
Are you applying on behalf of someone else? If yes, please complete details below:
Your Full Name
Your Address
Post code
Your Telephone number
Relationship to applicant
Signed ……………………………………………………. Date ………………………………….........
Please explain why they cannot apply themselves:
Part 5
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Leaving residential or institutional care or supported housing
If you are leaving residential or institutional care or supported housing, please
complete the details below:
By care we mean a prison, hospital, foster care, care home or similar place.
Name and address
of residential or
institutional care
or supported housing
Post code
Contact name
Telephone number
Date of leaving
Address to where you
are moving
Post code
Tell us about the help you need
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Part 6
Please tell us what help you need. The help must have a substantial and immediate
effect in resolving or improving your circumstances.
What do you need?
Why do you need it?
Who will use it?
Part 7
Other income
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Do you have any other sources to get money from (e.g. partner or relative, employment,
savings, property or other income)?
Please give details below:
Have you applied to any other funds in the last 12 months? And/or are you currently
applying to any other funds?
Yes – please say why and who you applied to with details, if you were refused or how much
you received. Please include contact details of where you applied.
No – please say why you have not applied to other funds
Part 8
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Check list
For your application to be considered you must:
Include copies of the relevant documents
Or
Enclose a letter from an agency/support worker to confirm they have copies of the
relevant documents and to confirm your eligibility
Please tick the ones that you have enclosed. You must sign this form
Proof that you live in Gloucestershire
For example:
Utility bill
Council tax bill
DWP letter
Proof that you are 16 years old or over
For example:
Birth certificate
Drivers licence
DWP letter
Proof of your benefits
Proof of priority group
For example:
A letter from your doctor
MATB1 form
Declaration – Please sign
I declare that the information I have given on this form is complete and correct to the best
of my knowledge.
I authorise the Award’s representatives to contact any agency, other organisation or
relevant person for clarification and/or confirmation of information relevant to my
application.
SIGNED ………………………………………………DATE …………………………………….
Please e-mail to: [email protected]
Auriga Services Limited administers the fund on behalf of Gloucestershire County Council.
Part 9
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Equal opportunities
To help us to monitor fair access, applicants are asked to provide particular information so that we have an
accurate picture. The information will also allow us to monitor our practices, to ensure that we do not
discriminate and help us to develop inclusive policies.
Please complete this part of the form so that we can check whether we are, in fact, receiving applications
from all sections of the community, and that applicants receive fair and equal treatment at all stages.
The information you give is confidentially managed and does not affect your application. It will
greatly assist us if you provide as much information as possible, but you are not obliged to do so.
What is your ethnic group?
Choose one section from (a) to (e) then tick the appropriate box to indicate your cultural background:
(a) White
 British
 Irish
 Any other White background
Please write in below
(b) Mixed
 White and Black Caribbean
 White and Black African
 White and Asian
 Any other mixed background
Please write in below
(c) Asian or Asian British
 Indian
 Pakistani
 Bangladeshi
 Any other Asian background
Please write in below
(d) Black or Black British
 Caribbean
 African
 Any other Black background
Please write in below
(e) Chinese or Other Ethnic
Chinese
 Any other
Please write in below
 Would rather not state
Do you consider yourself to have a disability? Yes  No  Would rather not state 
Which of the following best describes your religion/belief?
 Buddhist  Christian  Hindu  Jewish  Muslim  Sikh  None
 Other (please specify)
 Would rather not state
Which of the following best describes your sexual orientation?
 Heterosexual  Gay  Lesbian  Bisexual  Would rather not state
Which of the following best describes your gender?
 Male  Female
 Date of Birth
__ / __ / __
Age _______
Are you currently pregnant or have recently given birth? Please give age of youngest child
 Yes  No  Would rather not state
Age of youngest child:
Transgender: is your gender identity the same as your gender at birth?
 Yes  No  Would rather not state
Are you?
 Single  Married  Civil Partnership  Widowed or surviving partner  Would rather not state
If you are a carer please state the age of the children and / or people you are supporting:
1 _____
2 _____
3 _____
4 _____
5 _____
Data Protection
The information supplied on this form is being collected as part of the ‘Local Welfare Reform Offer’ procedures.
When you complete this form you are giving your consent to the Council to hold and use the information for service
improvement. The information you provide may also be disclosed to relevant statutory bodies
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Please use this page if you require extra space to add more information
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