APPLICATION FOR HELP WITH CURRENT CHARGE

1 Ref: BDSDate received:Telephone: 0300 123 TELL US ABOUT YOURSELFWHO SHARES YOUR HOME WITH YOU?MrNameFull name of each adultHow many children 16 and under live with you? How many children 16 and over live with you? Age of each child under 16 Age of each child over 16 AddressDate of BirthPhoneEmailPostcodeMrsMissMsOtherI live aloneIf YES, please tell us who Are you or anyone in your household disabled?WifeHusbandPartnerChildrenOther 1 APPLICATION FOR HELP WITH CURRENT YOU IN DEBT WITH ANY OF THE FOLLOWING? Amount of Weekly Arrears payment/offerRent Mortgage Secured loan Council tax Gas Electricity Court fines Amount of Weekly Arrears payment/offerHP agreements Catalogues Store/credit cards Loans Social fund loan Telephone Other (please specify) SEVERN TRENT WATER ACCOUNT NUMBER (as shown on your water bill)

2 INCOMEOUTGOINGSW ages/SalaryHousing CostsYour take home payRentPartner s take home payMortgageSecured loans/2nd mortgageCouncil taxLife/building/contents insuranceSupport for mortgage interestOther - please specifyJobseeker s allowanceUtilitiesUniversal creditWater/sewerageIncome supportGasElectricityChild tax creditCoal and other fuelsWorking tax creditHousekeepingMaternity pay/allowanceFood & general housekeepingClothingChildrenEmployment and support allowanceChild careStatutory sick paySchool meals living allowance (care) MaintenancePIP (daily living)TravelDisability living allowance (mobility)Car costsPIP (mobility)Fares - train/busCarer s allowanceMotability carSevere disability living allowanceHealthAttendance allowanceCare costs/special needsOther OutgoingsPensionsTV licenceState pensionSky/cablePension creditAppliance rentalPrivate pensionTelephone (inc. mobiles)Occupational pensionLoans (inc.)

3 Store cards, catalogues & HP)Partners pensionOther pension - please specifyOther IncomeOther - Please specifyMaintenanceStudent grant loanIncome from lodgers or propertySon s/daughter s contributionContribution from other adult at propertyOther - please specifyWEEKLY FIGURESWEEKLY FIGURESWhat (if any) savings do you have?TOTAL WEEKLY INCOMETOTAL WEEKLY OUTGOINGSC ouncil tax support IT IS ESSENTIAL TO PROVIDE PROOF OF ALL HOUSEHOLD INCOME WITH YOUR APPLICATION (SEE SECTION 6 FOR DETAILS). SHOW ALL HOUSEHOLD INCOME AND EXPENDITURE2 Advice agencies may submit their own financial statement if preferred 1) Are you:Employed full-timeEmployed below minimum wageRetiredEmployed part-timeEmployed zero hoursUnemployedEmployed via an agencySelf employedStudent2) Are you: In receipt of a means tested benefitYesNoWaiting for a decision regarding a means tested benefitAppealing against a decision not to award a means tested benefit3) Is anyone in the household:Receiving a disability benefit Waiting for a decision regarding a disability benefit Appealing against a decision not to award a disability benefit 4)Is anyone in the householdaged between.

4 60-7475-8990 or over5)Do either of the followinglive in the householdDependent childrenElderly relatives 6)Do any of the following apply to you:Benefit capBedroom Tax (one room) Bedroom Tax (two rooms) Non-dependent deductionsLocal housing allowance (LHA)7)Are you applying for adebt relief order withinthe next 7 days:(Please tick all thatapply to you)YesNoYesNo(Please tick all thatapply to you)(Please tick all thatapply to you)YesNoYesNoYesNo(Please tick all thatapply to you)(Please tick all thatapply to you)(Please tick all thatapply to you)YesNoSTTF BDS ONLY Form Page 1 11/04/2016 14 TICK ALL THAT APPLY TO SOMEONE HAS HELPED YOU TO COMPLETE THIS FORM, PLEASE ASK THEM TO ADD THEIR SUPPORTING HELP US TO HELP MORE PEOPLESo that we can consider your APPLICATION quickly, please remember to provide up to date PROOF OF ALL HOUSEHOLD INCOME with your APPLICATION for yourself, partner and any other adults and documents must clearly show name and address details as well as the amounts currently being can scan or photograph proof and return as an attachment if submitting this APPLICATION via email or can enclose photocopies of documents if returning via Number.

5 1108278 Registered in England No: 0533882705/164 Signature:Date:Severn Trent Water Charitable Trust Fund is an independent charitable Trust. Independent Trustees oversee the policy and development of the Trust. The day to day management of the Trust is undertaken by Auriga Services Limited within guidelines and delegation set by the Trustees. NameJob TitleOrganisationAddressEmailSignaturePo stcodeTelephoneDatePLEASE RETURN THE COMPLETED FORM VIA EMAIL POST TO: SEVERN TRENT TRUST FUNDFREEPOST RLZE-EABT-SHSA SUTTON COLDFIELDB72 1 TJI declare that the information I have given on this form is complete and correct to the best of my authorise the Trust or their representative to (a) contact the supplier of my water/sewerage services and any referral agency, other organisations or relevant person for clarification and/or confirmation of the amounts owing or other information, which the Trustees consider relevant to my APPLICATION .

6 (b) provide relevant information to the water/sewerage company to enable future budgeting of water charges, and (c) provide relevant information to my energy supplier/relevant Trust Fund/Advice Agency for the purpose of seeking additional grant aid or money advice. I agree that you can contact me in the future to ask about the service I have received, this helps us to improve our service for tell us where you heard about the Big Difference Scheme and where you got the APPLICATION form from.