Please enable JavaScript in your browser to complete this form.Why are you contacting us?I would like to refer a client to your serviceI’m seeking help for myselfPersonal InformationYour name *FirstLastWhat is the name of your organisation? *Email *Phone *What is the name of the person receiving benefits? *FirstLastBenefits recipient’s email *Benefits recipient’s phone number *Benefits recipient’s address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryBenefits recipient’s date of birth *Benefits recipient’s relationship status *SingleCouplePartner’s name *FirstLastPartner's date of birth *Current BenefitsAre you or your partner receiving any of the following benefits: *Tax CreditsUniversal CreditsJSAESAAny other benefitsNone of the aboveTax Credit amount received in £ *Tax Credit *Per WeekPer MonthUniversal Credit amount received in £ *Universal Credit *Per WeekPer MonthJSA amount received in £ *JSA *Per WeekPer MonthESA amount received in £ *ESA *Per WeekPer MonthOther benefits: *If there are any benefits please list them in this box provided above and include the amount received per week/month.HealthDo you/partner consider yourself to have an illness or disability? *YesNoAre you/partner getting any of these benefits? *DLAPIPAANone of theseCaring For SomeoneAre you/partner a carer for a sick or disabled person? *YesNoAre you/partner already claiming Carer’s Allowance? *YesNoChildrenHow many dependent children living in the household? *If so, what are their ages? *What gender are they? *MaleFemaleAre any of these children disabled? *YesNoAre you already claiming a disability benefit for any children? *YesNoHow much disability benefits do you receive in £ per week/month? *Do you have any childcare costs? *YesNoHow much in £ per week/month? *Your HomeWhat is your current housing status? *RentedOwner/OccupierOtherNumber of bedrooms: *How much rent do you pay per week/month? (£) *Do you receive housing benefit/help with housing costs? *YesNoIf so, how much? (£) *Outstanding Mortgage: (£) *Number of other adults living in household/non-dependants: *What Council Tax Band are you in? *Money & WorkAre you or your partner working? *YesNoHow many hours worked per week? *Gross Earnings (£): *Savings & Property Do you or your partner have any savings? *YesNoAmount (£): *Do you or partner own land or property other than your current home? *YesNoDo you or your partner receive any other income eg occ pension, maintenance, lodger income etc *YesNoAmount (£): *DebtsDo you or your partner have any debts? *YesNoAre any deductions being made to your benefits or earnings to pay for any debts? *YesNoData retention policy *We keep contact details and equal opportunity information in a database that only Citizens Advice can access. We will not pass any information on to a third party. We would like to retain the information only for the following purposes: to make follow up calls, send emails from time to time enabling us to gain valuable feedback into people’s experience of the national volunteering telephone and online volunteer recruitment process, to find out whether or not those people are volunteering with us and for evaluation purposes. We also keep equal opportunity information for statistical purposes.Please tick the box to show that you have read and understood our Data Retention Policy. By submitting this form you agree to send the information provided in the form via unencrypted email to our secure email server. Submit
