Do you have a claim reference number?

Yes

No

Are you completing this form on behalf of someone else?

Yes

No

How did you find out about the LWP scheme?

Benefits Team

Citizens’ Advice

Department for Work and Pensions

Tenancy Support Officer

Transform

Other

Address:

Address line 1:

Address line 2:

City/Town:

County:

Postcode:

How long have you lived at your current address?

Less than 6 months

1 year

2 to 5 years

5 to 10 years

Over 10 years

Are you subject to any restrictions in applying for public funds?

Yes

No