Temporary referral form

This form should be completed by an individual working at a recognised referring organisation (the "referring agent") on behalf of the intended recipient (the "applicant").

Referrals being made

Recipient / applicant details

Please give details of the intended recipient / applicant. This is the details of the client who is in need, not your details as the referrer.

Recipient's address (including postcode) - for Starter Packs, this should be the address they are moving into *

Starter pack referral

Previous address (including postcode) *

Reason for leaving previous address *

Other relevant information

Bedding

Please tick required items and select size.

Bedding
DuvetBedding setPillows

Bedding size
SingleDouble

Household items

Please tick required items.

Crockery, cutlery, pans and utensilsKettle

Recipient's date of birth (dd/mm/yyyy) *

Acts435 referral

Item requested *

Amount requested.
This should be the actual cost of the item above. Please cost your item and apply for the actual amount required, rather than simply applying for the maximum amount: larger requests take longer to fund. Generally requests should not exceed £150, except for cookers / washing machines / fridge freezers (£200) or fridges / freezers (£175). Smaller electrical items such as vacuum cleaners and mobile phones are limited to £100, or £75 for microwaves. Not following these instructions will delay your application. *
£

Please give a paragraph explaining why the applicant requires the item(s) requested. This paragraph (which may be edited) will be the basis on which people are encouraged to donate towards meeting this need, so please include specific details of why the applicant has this particular need, why they can't afford it themselves, and any other relevant information as to why they are in their current situation. *

Referring agent

Collection

When would you ideally like to collect the pack/grant? Please note that we cannot guarantee to meet this but we will do our best. If you are flexible, please give a range of dates and/or times, or leave blank.

Declaration

I confirm that the applicant named above is in genuine and urgent need, is unable to obtain these items from another source at this time.

I confirm that the applicant has given consent to have these personal details shared with Inn Churches and Acts 435 and that they understand that their story will appear anonymously on the Acts 435 website for people to donate towards. I also confirm that the applicant has agreed to the sharing of any sensitive information such as racial or ethnic origin, criminal offences committed, or physical and mental health.

I commit to returning receipts for the purchase(s) within two weeks if possible, and to requesting permission if they will not be returned within a month. I understand that if receipts are not returned within two months then the funding may be withdrawn.

Diversity monitoring

This information is optional and for monitoring purposes only. It will not be considered when assessing the referral.