Options form (pdf 389kb) - Switchover Help Scheme

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

Resident details:
Title: Mr Mrs Miss Ms Date of birth
First name
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme Details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
No (Please put a cross).
nX
n X
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn

Resident details:
Title: Mr Mrs Miss Ms Date of birth
First name
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
No (Please put a cross).
nX
n X
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn

Resident details:
Title: Mr Mrs Miss Ms Date of birth
First name
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
First name
No (Please put a cross).
nX
n X
Resident details:
Title: Mr Mrs Miss Ms Date of birth
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nX nX nX nX
nnnnnnnn
nnnnnnnnnnnnn Surname nnnnnnnnnnnnnn
nnnnnnnnn
nnnnnnnnnnnnnnnnnn Room number nnn
National Insurance number
Reference number
Help Scheme details: Yes
Help Scheme help n X
Standard option n X
Other option
Confirmation:
*Signature
No (Please put a cross).
nX
n X
Yes
Free n X
£40 n X
Other cost
Self-certification †
Relationship
to resident
n X
No
nX
n X
nX
Total
Payment method
Cheque n X Cash n X
Card n X
(via giro slip)
Call us with your card details
nnnnnnnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn
nnnnnnnnnn