Options form (pdf 389kb) - Switchover Help Scheme
Options form (pdf 389kb) - Switchover Help Scheme
Options form (pdf 389kb) - Switchover Help Scheme
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Option selection<br />
Care home number<br />
TV Licence status<br />
Care Home Manager contact details:<br />
X X X X<br />
Title: Mr n Mrs nMiss n Ms n Other nnnnnnnnnnnnnnnnnnnn<br />
First name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn<br />
Surname nnnnnnnnnnnnnnn Positionnnnnnnnnnnnnn<br />
Mobile phone nnnnnnnnnnn E-mail nnnnnnnnnnnnnnnn<br />
Resident details:<br />
Please use this as an example<br />
Title: Mr Mrs Miss Ms Date of birth<br />
First name<br />
n X nX nX nX<br />
nnnnnnnn<br />
1 9 0 8 1 9 7 5<br />
nnnnnnnnnnnnn<br />
A L A N<br />
Surname nnnnnnnnnnnnnn<br />
S M I T H<br />
nnnnnnnnn<br />
J C 9 1 4 7 6 3 D<br />
nnnnnnnnnnnnnnnnnn<br />
F C 4 5 7 9 2 1 S<br />
Room number nnn 1 2 3<br />
National Insurance number<br />
Reference number<br />
S<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes No (Please put a cross).<br />
<strong>Help</strong> <strong>Scheme</strong> help n<br />
X nX<br />
Free<br />
Standard option n X n<br />
X<br />
£40<br />
Other option<br />
Other cost<br />
skeym cour cooney<br />
Confirmation: lesh y chaghlaa<br />
*Signature<br />
Self-certification skeym cour cooney<br />
†<br />
lesh y chaghlaa<br />
Relationship<br />
to resident<br />
n X<br />
Cheque Cash<br />
Card skeym n X<br />
(via cour giro slip) cooney<br />
Call us with lesh your card y chaghlaa details<br />
Self-certification<br />
†I confirm that I receive one or more of the following benefits which make me eligible to<br />
receive free help from the <strong>Switchover</strong> <strong>Help</strong> <strong>Scheme</strong>: pension credit, income support,<br />
income-based jobseeker’s allowance or income-related employment and support allowance.<br />
Residents declaration<br />
* A signature is required from the eligible person unless:<br />
• You have power of attorney for them.<br />
• They can’t manage their affairs due to a mental disability or learning disability.<br />
• They have a specific disability which makes it impossible for them to fill in this <strong>form</strong>.<br />
skeym cour<br />
skeym cour<br />
skeym cour<br />
Any cooney queries? lesh Call the Care Home Team on cooney 0800 lesh 40 85 933.<br />
cooney lesh<br />
Opening y chaghlaa times: 9am to 5pm Monday to y Friday. chaghlaa<br />
y chaghlaa<br />
Yes<br />
No<br />
n X nX<br />
Total<br />
n n<br />
£ 3 1 0<br />
X X Payment method<br />
n<br />
n<br />
X £ 3 1 n<br />
0XX X<br />
X<br />
nnnnnnnnnnnnnnn<br />
C A R E H O M E M A N A G E R<br />
nnnnnnnnnn<br />
9093 - CH002 12/10
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
First name<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> Details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
First name<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
First name<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
First name<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Resident details:<br />
Title: Mr Mrs Miss Ms Date of birth<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nX nX nX nX<br />
nnnnnnnn<br />
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn<br />
nnnnnnnnn<br />
nnnnnnnnnnnnnnnnnn Room number nnn<br />
National Insurance number<br />
Reference number<br />
<strong>Help</strong> <strong>Scheme</strong> details: Yes<br />
<strong>Help</strong> <strong>Scheme</strong> help n X<br />
Standard option n X<br />
Other option<br />
Confirmation:<br />
*Signature<br />
No (Please put a cross).<br />
nX<br />
n X<br />
Yes<br />
Free n X<br />
£40 n X<br />
Other cost<br />
Self-certification †<br />
Relationship<br />
to resident<br />
n X<br />
No<br />
nX<br />
n X<br />
nX<br />
Total<br />
Payment method<br />
Cheque n X Cash n X<br />
Card n X<br />
(via giro slip)<br />
Call us with your card details<br />
nnnnnnnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn<br />
nnnnnnnnnn