Self referring to The Bridge

Applicant's name *

First Name

Last Name

Source of income in the household *

Earning, no benefits (includes pension income)

Earning and benefits (includes child benefits)

Benefits, no earning

Income but no or insufficient access to it (eg, no access to a bank account)

No income

Decline to answer

Financial - earnings related

Change in work hours

Unemployment following permanent work

Unemployment following temporary work

Delay in or awaiting other income

Financial - benefits related

Benefits delay

Benefit deduction due to overpayment or benefits advance

Benefit reduction due to change in eligibility

Benefit reduction due to sanction

Awaiting first benefit payment for less than a month

Awaiting first benefit payment for more than a month

Financial - debt, costs and expenses

Priority debt eg, rent or mortgage, gas or electricity bills, court fines

Non-priority debt eg, credit cards, unsecured loans from friends and family

Cost of dependents has increased eg, increased costs due to summer holidays

Rising cost of essentials

Other unexpected expense

Personal circumstances

Insecurely housed

No access to financial support due to immigration status

Loss of support from friends or family

Change in relationship status

Domestic abuse

Change in dependents

I have read and agree with the following statement *

Walton & Hersham Foodbank and Walton Charity use your personal information to help understand your needs and provide you with emergency food. Access to your information is restricted and can only be seen by the agencies who refer you and by Walton & Hersham Foodbank, Walton Charity and authorised people in the Trussell Trust foodbank network who have a legitimate interest and will use the data for statistical and research purposes, showing how food banks are being used and why they are needed To find out more about your rights or about how the Trussell Trust keeps your information safe, see the Trussell Trust privacy statement www.trusselltrust.org/privacy. For more about Walton Charity's privacy statement and sharing protocol see www.waltoncharity.org.uk/privacy.

Yes

Date *

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