HHS Grant Application Form

Name

Address

Contact telephone/mobile phone number

Email address

Do you receive housing benefit?

Yes

Do you receive the housing element within your Universal credit award?

Yes

Do you receive Discretionary Housing Payment

Yes

Do you have rent arrears?

Yes

NB if you have answered Yes. Please ensure that you provide evidence of this, such as a rent account statement or screen shot of your rent account detailing the last 6 months transactions.

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png.

Please explain the reason for your application for an Exceptional Household Support Payment. (Please provide evidence to support your request)

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