Form

Quids for Kids referral form

For benefit information and advice
Due to the high volume of enquiries there is a 3-4 week delay in contacting clients in all Local Authority Districts. If you cannot wait this long for advice, please ring Devon Citizens Adviceline on 03444 111 444.

Please note that if you think you will miss a deadline for returning a Personal Independence Payment (PIP) form, you can ring and ask for an extension. There is no formal extension process for Disability Living Allowance (DLA) but you can discuss your claim on the DLA enquiry line.

For PIP ring : 0800 121 4433

For DLA enquiries: 0800 121 4600
Are you completing this form for:

Benefits for myself Benefits for a member of my family Client of the agency I work for
Agency Name
Agency Contact Name
Agency Contact Tel
Agency Contact Email
Do you have the clients permission to share this information with CAB Devon

Yes No
Are you applying on behalf of a:

Young person, aged 16 to 21 Family with children
Applicant's Details
First Name *
Last Name *
Date of Birth

- Day - Month Year
E-mail
How many children do you have with additional needs that require benefit help? *
Child's First Name *
Child's Last Name *
Child's date of birth

- Day - Month Year
Child's Illness or Disability *
2nd Child's First Name
2nd Child's Last Name
2nd Child's date of birth

- Day - Month Year
2nd Child's Illness or Disability
3rd Child's First Name
3rd Child's Last Name
3rd Child's date of birth

- Day - Month Year
3rd Child's Illness or Disability
4th Child's First Name
4th Child's Last Name
4th Child's date of birth

- Day - Month Year
4th Child's Illness or Disability
If you have more than 4 children with additional needs, please add their details at the end of the form.

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Local Authority District where you live *
We need this information to direct you to your nearest specialist adviser.
Find your local authority by postcode.
Preferred Tel Number *
Is it OK to leave a message on this phone

Yes No
Is it OK to leave a SMS (text) message on this phone

Yes No
Any special contact instructions, including days/time available?
Which day can we contact you

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What is the best time to call you

Morning Afternoon Either
Are you claiming any of these benefits as a household.

Housing Benefit Council Tax Support (Old Council Tax Benefit) DLA PIP Child Tax Credit Working Tax Credit Carers Allowance Job Seekers Allowance Income Support Employment and Support Allowance
What help with benefits do you require?
If you haven't claimed DLA (Disability Living Allowance) for a child under 16 before and you think he or she could get it, please order a claim pack as soon as possible from the DLA helpline on 0800 121 4600. For more information and call costs visit www.citizensadvice.org.uk - DLA for children.
If there is a key date by which your application must be dealt with, please enter the date here

- Day - Month Year
Client consent

At Citizens Advice we must ask for your consent to record, use or share personal information. This form is used to do that. For more information, please see the Citizens Advice Devon privacy policy.

Permission and consent

When we record and use your personal information we:
- only access it when we have a good reason
- only share what is necessary and relevant
- don't sell it to commercial organisations
We need to record information about you to help with your enquiry. We have a legitimate interest to do this.
I consent to you recording and using my personal data *

Yes No
We need your consent to record and use your special category personal data

We need your explicit consent to use some information, including your ethnicity, religion, health conditions and sexual orientation.

If you agree, we'll use this information, which is known as 'special category personal data', to:
- give you advice
- help us gather data to improve our services
- support our research in a way that you can't be identified
We'll make sure all your information is kept safe in our secure case management system.
I consent to your holding information on my (please tick all of those you agree to): *

Health conditions (you must select this option) Ethnicity Religion Sexual orientation
Please note that due to the nature of this service you must tick the Health Conditions consent box above in order for us to be able to assist with a claim.
Can we contact you for feedback?

We want to make sure our service meets your needs. To help us understand how we're doing and to improve our service, we may want to contact you at a later date to ask for your feedback. Sometimes we need a trusted research organisation to help us do that.

We'll decide who we contact for feedback based on the services you used and the advice area. We may also use your special category data so that we hear from different groups.
I agree to Citizens Advice selecting me for feedback using my information and contacting me *

Yes No
Should be Empty:

Quids for Kids referral form