You are Referring another person, the Applicant, to be evaluated for an award from the Household Support Fund scheme

    Please complete the form below, clicking the checkbox as appropriate

    Referrer's Details






    Applicant's Details





    Is the applicant an existing client of Dial West Cheshire?

    Is the applicant in receipt of or applied for benefits?

    Is the applicant making a request for support from any other organisation?

    What type of support does the applicant need?

    Food

    Energy and water (eg help with domestic bills such as water, gas, electric)

    Essentials linked to energy and water

    Wider Essentials not related to energy and water

    By submitting this form the Referrer and Applicant agree to Dial West Cheshire processing and storing their details in accordance with our privacy notice Privacy & Cookie Notice. In addition, the applicant agrees to us checking the information provided and where appropriate making a referral to another partner organisation which might be able to offer help and support.