Tandridge District Council Forms

Anyone who meets the eligibility criteria and is asked to self-isolate on or after 28 September will be entitled to the new payment and will receive backdated payments from the scheme.

Your Contact Details

First name

Last name

Address

Please search on Postcode or Number and Street Name

Address

Date of birth

National Insurance Number

E-mail address

Primary contact telephone number

Contact mobile phone number

UPRN

Council Tax Account Number

This is not essential but if supplied will speed up your application process. You can find your council tax account number in the top right-hand area of the first page of a council tax bill.

Nature of Employment / Self Employment

Name of Employer

Nature of Employment and explain why you cannot work from home

Are you Claiming at least one of the following benefits?

An applicant can make a claim for each period of self-isolation. All eligibility criteria must be met and supporting evidence provided.

Benefits Reference Number

This is not essential but if supplied will speed up your application process.

Have you made a previous application for the COVID-19 Test and Trace Payment Scheme?

YesNo

Please provide dates of previous claim(s)

Proof of Eligibility

A bank statement showing your name and address as supplied earlier

Will supply bank statement at a later date

Proof of receipt of one of the qualifying benefits

Will supply proof of benefit at a later date

Proof of employment or if self-employed, evidence of a self-assessment return, trading income and proof that the business delivers services which cannot be undertaken without social contact.

Will supply proof of employment at a later date

Bank Details

You will receive this payment via BACS transfer. This payment will be for £500 and is subject to tax. However, you will not be taxed at the point of payment and will be contacted by Her Majesty's Revenue and Customs (HMRC) at a later date.

Name of bank account holder

Name of bank

Bank sort code

Bank account number

Declaration

Please read the declaration carefully before you complete it.

Tandridge District Council may prosecute you if you give false information.

If you receive a payment that you are not entitled to, you must return the payment to us immediately.

I agree to self-isolate for the required period.

I declare that to the best of my knowledge, the particulars given on this form are true, accurate and complete. I understand that if I give information that is incorrect the Council may take action against me which could include court proceedings.

I agree that the council can access my records contained in the NHS Test and Trace Data System (CTAS) for the purposes of confirming my eligibility for this scheme of payment.

I undertake to notify Tandridge District Council of any changes that may affect my entitlement to any payment.

I confirm that I will lose income as a result of having to self isolate.

Your data will not be shared with other entities outside of the Council for any purpose and you may withdraw your consent at any time by contacting the Council. Please be aware that if you do withdraw your consent, you will no longer be entitled to the payment under this scheme.

In the absence of proof, we will use all information available to validate the details given in this form and may contact you for further information

Name

Date

COVID-19 Test and Trace Support Payment Scheme

Your Contact Details

Eligibility Criteria

Eligibility for Test and Trace Support Payment

Nature of Employment / Self Employment

Are you Claiming at least one of the following benefits?

Proof of Eligibility

Bank Details

Declaration