Local assistance Form

LOCAL ASSISTANCE SCHEME

APPLICATION FORM
Name *

First Name Last Name
Date of birth *

Month Day Year
National Insurance Number
Partner name if applicable

First Name Last Name
How many children under 16 are in the household
Email
example@example.com
Phone number *
Are you self isolating because a member of your household is: *

over 70 disabiled or underlying health condition Pregnant Not applicable
This information is shared with Somerset County Council as the scheme is funded by the SCC and administered by West Somerset Advice.
Please confirm that you give consent to hold your information and contact you.

Yes I give consent to hold my details and contact me about this application.
What help do you need from the Local Assistance Scheme?
Have you contacted your supplier for Gas or Electricity keys

Yes No Was not aware that they could assist Does not apply to me
Who is your supplier and what have they done to help you?
Please upload a bank statement, proof of your benefit or wage slips showing that you do not have resources.

If you need to check if you can claim a benefit please call 0800 802 1808
Recent bank statement

Browse Files

Cancel of
Benefit proof

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Cancel of
Other information

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Cancel of
Bank account sort code
Bank account number
Please sign

Clear
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LOCAL ASSISTANCE SCHEME