Please complete all sections Please note: only applications from registered referral organisations will be accepted. Complete all sections of this form - incomplete applications will be rejected. About the funding recipient About the funding recipient / qualifying household Households Households containing at least one person of pension age Households containing at least one disabled person up to the age of 64 Household numbers Regardless of Household Support Fund eligibility, how many people in the household are: Qualifying recipient’s name Important criteria IMPORTANT: If the qualifying recipient is aged under 16 (i.e. in the disabled people category), please only enter the name of their parent or adult guardian. However, all other details provided must relate to the qualifying person. State the specific electoral ward they are based in Ancoats & Beswick Ardwick Baguley Brooklands Burnage Charlestown Cheetham Chorlton Chorlton Park Clayton & Openshaw Crumpsall Deansgate Didsbury East Didsbury West Fallowfield Gorton & Abbey Hey Harpurhey Higher Blackley Hulme Levenshulme Longsight Miles Platting & Newton Heath Moss Side Moston Northenden Old Moat Piccadilly Rusholme Sharston Whalley Range Withington Woodhouse Park Housing Tenure - state which of the following is most applicable Social rent Private rent Owner State the main need for which this funding is requested Food Essentials linked to energy and water Other essentials (please specify) Housing costs (only to be allocated in exceptional cases of genuine emergency) Please specify the housing costs and why they are needed here Please specify the other essentials here Amount requested £300 Funding will be paid to referral organisations by bank transfer. However, state the funding recipient’s preference as to how they will receive the money from your organisation BACS Cash Cheque Goods in-kind State any important information about the recipient that is relevant to this application (e.g. at risk of becoming homeless, serious health problems, etc.) Declaration Declaration The recipient has given their consent for the information in this form to be shared and know who it’s shared with Yes No Application forms are handled in strict confidence by a single administrator and where appropriate anonymised before being shared with other relevant parties. Anonymised data may be used to generate statistics e.g. about numbers accessing the fund and types of situation that people are in. Info correct All the information supplied is correct to the best of my knowledge. I am authorised to submit this application on behalf of our organisation (signature not required). Your name Organisation name - Select -African Caribbean Mental Health ServicesAge UK ManchesterCheetham Hill Advice CentreEqual Education ChancesGaddumGeorge House TrustGreater Manchester Coalition of Disabled PeopleHopewellJustlifeManchester Action on Street HealthManchester Refugee Support NetworkThe Message Community GroceryTree of Life CentreWythenshawe Good Neighbours Role in organisation Your telephone number Your email address Equalities monitoring for the funding recipient Equalities monitoring for the funding recipient State whether the qualifying person is registered disabled (if your referral is being made under the “disabled” rather than “pension-age” category, and you are selecting option 'No' or 'Prefers not to say', please use the box below to briefly explain why you are referring them as “disabled”) Yes No Prefers not to say Please briefly explain why you are referring them under the disabled people category State the lead recipient’s sex Man Woman Intersex Non-binary Uses own term (specify) Prefers not say Please specify the own term the lead recipient uses for their sex State the qualifying person’s age (if the qualifying household member is disabled and of pension-age, please ensure you have selected “Households containing at least one person aged 65 or older” at the top of this form. If they are aged under 65, they must be a disabled person to be eligible for funding) 16-29 30-39 40-49 50-59 60-64 65+ Prefers not to say State the lead recipient’s ethnicity (not nationality) English Welsh Scottish Northern Irish British Gypsy or Irish Traveller Other White ethnicity [specify] White and Black Caribbean White and Black African White and Asian Other mixed background [specify] Indian Pakistani Bangladeshi Chinese Other Asian background [specify] African Caribbean Other Black background [specify] Arab Any other ethnic group [specify] Prefers not to say Please specify other White ethnicity Please specify other mixed background Please specify other Asian background Please specify other Black background Please specify any other ethnic group State the sexual orientation of the lead recipient Heterosexual Gay Lesbian Bisexual Uses own term (specify) Prefers not say Please specify the own term the lead recipient uses for their sexual orientation State the religion of the lead recipient None Buddhist Christian Hindu Jewish Muslim Sikh Other religion (specify) Prefers not to say Please specify the other religion State whether the lead recipient is employed or not Yes No If employed, state their working pattern Full-time Part-time Prefers not to say Not applicable State whether the lead recipient has caring responsibilities None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Other (specify) Prefers not to say Please specify other caring responsibilities