Expression of interest form (EOI) (pdf 2mb) - Switchover Help Scheme

Expression of interest

Office only

Please fill in this form in block capitals only.

Please use either blue or black ink.

Care home reference

Care home manager’s declaration

I confirm that the people listed overleaf have lived in care homes for a continuous period of

six months or longer. They were living in this care home when I received the letter ‘Changes to

the Digital Switchover Help Scheme for residents of care homes’. Each resident or someone

authorised to act on their behalf (their authorised representative) has read the Resident’s

declaration (below). As far as I know the information provided is correct.

Please include details of all residents in your care home who qualify for assistance

(all residents staying for over six months).

Care home manager’s signature

Date / /

DSHS Limited, are the data controller for the Switchover Help Scheme.

Resident’s declaration

I would like to receive more information from the Switchover Help Scheme about ways of

getting help to convert my TV to digital. I agree for my personal details to be sent to and held

by DSHS Limited, who run the Help Scheme. I agree to DCMS contacting the Department for

Work and Pensions and TV Licensing to check that I am eligible for help from the Help Scheme

and to check whether I qualify for free help or would have to pay the £40 contribution fee.

5613 - DCMSEOI 03/10

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First name

Surname

Room number

X X X

Please use this as an example.

1 3 0 3 1 9 7 2

K E V I N A N D R E W

S M I T H

National Insurance number

J C 9 1 4 7 6 3 D

Name of authorising person

1 2 3 (if not the resident)

A L A N S M I T H

Relationship to

resident

C A R E M A N A G E R

Title: Mr Mrs Miss Date of birth

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

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Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

---

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)

Title: Mr X Mrs X Miss X Ms X

Other Date of birth

First name

Surname National Insurance number

Room number

Name of authorising person

(if not the resident)

Relationship to

resident

Authorised signature

(resident or other authorised person)