Applicant Details

Name of applicant

Address

Telephone/mobile number

Household Details

Do you, or anyone in your household have any disabilities/vulnerabilities? Please provide details.

Are you, or anyone in your household getting support form any other organisations?

For example Citizens Advice, food banks, debt support company etc.

Are you, or anyone you live with employed?

Yes

Do you, or anyone you live with receive benefits?

Yes

Financial Details

Please tell us about any other income you receive (private pensions, dividends, etc.)

Do you, or any adult you live with have savings over £500?

You will need to provide bank statements covering the last month for all named tenants on your tenancy agreement.

Do you have any outstanding debts or unpaid bills? Please list the amount owed and to whom.

On Behalf of Applicant Details

Has this form been completed on the applicants behalf?

Yes

Declaration

I confirm the information I have provided is true and accurate. If mhs homes were to find any of the information given during the application to be inaccurate, action can be taken against me personally, including paying back any monies paid incorrectly.

I consent to mhs homes using the information given to process my eligibility mhs homes may verify my details with the information held on my tenancy.

I authorise mhs homes to make the necessary enquires to check the information I have provided is correct. This may include mhs homes contacting or visiting me to discuss my application.

I may withdraw my consent at any time by emailing contactus@mhs.org.uk. If you do withdraw your consent, you may no longer be entitled to payments
under the scheme.

If this application was completed by someone on your behalf, you confirm each question and response has been read to you and that you understand
this declaration.

To find out how we process your personal data read our privacy notice
https://www.mhs.org.uk/legal/privacy-notice/

Tick to confirm you have read and agree with the statement above.

Uploads

Please upload recent bank statements showing at least one month of transactions.

Bank statements should be provided for all named tenants on the tenancy agreement.

I can't upload a bank statement right now

I can't upload a bank statement right now, but I understand that I'll still need to provide a statement before my application is assessed.

If you are applying for an electricity or gas top up voucher please attach a photo of your meter reading showing the credit or debt on the meter.

Apply for our Customer Support Fund