Welfare Benefits Referral Form

Use this form to ask for help with claiming benefits or to request a benefit check.
If you need help in completing this form please contact 01432 363756.
Fair obtaining notice
Please agree to the following Fair Obtaining Notice before filling out this form.
The Data Protection Act 1998 gives rights to you about how your personal data is obtained and used by Herefordshire Council (the 'data controller') when you fill in this form. The information you provide will be used to process this form only and not kept any longer than is necessary for this purpose. Information which must be provided to process this form is shown by an ' * '. All other information fields are optional. Please read our Privacy Statement for further information.
I agree to these terms: *
Are you completing this form for yourself or someone else?
If you are filling this form in for someone else please complete your details.
Your name: *
Your relationship to the person needing help. If you are a professional please state the organisation you work for. *
Your telephone number: *
Your email address: *
Details of person needing help
Title:
Other
First name: *
Last name: *
House name/number: *
Street name: *
Town/City: *
County:
Postcode: *
Home telephone:
Mobile telephone:
Email Address:
Date of birthDay
MonthYear
Age
Living arrangements
Please select 'Next ' to continue completing this form.

Last Updated: 19 January 10

Fair obtaining notice