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Tell us who you are
Tell us who is filling out this form
I am filling out this form for myself
I am filling out this form for someone else
Does the person you are referring claim any benefits?
Yes
No
Do you claim any benefits?
Does the person you are referring claim any benefits?
Do you claim any benefits?
Yes
No
This form is only to be used by people who do not claim any means-tested benefits.
Please make an application to the Local Social Discretionary Fund instead
Get emergency help with food, energy bills and other essentials
Does the person you are referring know you are making this referral?
Yes
No
Please make sure you have the person's consent. If not, please explain why this is not possible
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