Unity Community (UC)
Assessment Form
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WE CAN NO LONGER TAKE PERSONAL REFERRALS, PLEASE CONTACT A SOCIAL WORKER, OUTREACH WORKER, DV OFFICE, CHARITY OR COUNCIL.
If you are filling in this form by referral of friends or family, please know that we will NOT be able to help you till an official agency is involved with your case. Only an official agency should be referring you to us.
Full Name *
Telephone Number *
Address: Flat or House number / name *
City *
FULL Postcode *
How many Adults in the House  (18 years old and above)? *
How many Children in the House (0-17 years old)? *
Are you working?  *
Required
If you are not working, Why are you not working? *
What benefits do you get (select all the ones that you get) *
Required
How much TOTAL amount of money do you (FULL FAMILY INCLUDING HUSBAND, WIFE, KIDS, ETC) receive from the Council, including the total amount on ASPEN card Asylum seekers. (Total for all family members). Per week or per month? *
You will provide us with your latest 3 months bank statements if you are receiving benefits. Or you will send us proof of Asylum Seekers (ARC card). We will not be able to help if you cannot provide us with this. *
Are you taking help from any other charities? If so please give their names and contact number here. *
Are you a Muslim? (This is only for the purpose of Ramadan & Zakah) *
If you are a Muslim, do you take Zakah *
Where did you find out about us? *
Full Name of the person who referred you *
Name of the organisation who referred you? *
Contact Number for the person/official who has referred you? *
Bank Details
At times we are unable to drop food so we need bank details to transfer money bank to bank instead.
FULL NAME OF ACCOUNT HOLDER *
SORT CODE *
ACCOUNT NUMBER *
Disclaimer: I take full responsibility of providing the correct bank details for Unity Community to transfer funds to my bank account. I will not hold Unity Community accountable for any issue resulting from any mistake. It is my responsibility to update Unity Community if there are any changes to my account. I will not hold Unity Community liable for anything. Note: If you disagree then we will not be able to transfer any money to you. *
Required
TERMS AND CONDITIONS
1. PLEASE KNOW: 
We are only taking referrals from officials. 
WE can only help FOR 3 MONTHS.
This is only a small voluntary organisation with very limited funds. This is NOT a registered charity.
2. GDPR: You give us the right to share your details with 3rd Party, who can also contact you if need be.
3. You are filling in this form because you are in desperate need of food?
4. Everything you have stated here is true. If it is not true, we will stop helping you.
5. As soon as you are able to manage, you will let us know so we can remove you and add more desperate families to our list
6. We will not be able to take references from family/friends unless there is a case worker involved or an official involved.
7. WE WILL ASSESS YOUR SITUATION AFTER 3 MONTHS. WE CANNOT PROVIDE HELP PERMANENTLY.
8. We will be asking for your bank statements and universal credit accounts and ARC card or other paperwork if needed.

I have read and agree with the Terms and Conditions *
Required
Date of filling the form *
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