I am applying for:

Fuel Top Up

Mobile Phone Top Up

Please complete the form.

Please select each and any box that applies to you or your household:

Does a member of your household receive DLA/PIP or Attendance Allowance?

Do you or a member of your household have a medical condition?

Is a member of your household on sick leave with a Doctor’s line?

Do you have access to a landline or mobile with credit?

Are there children aged under 18 or adults over 70 in your household?

Is a member of your household over 65 with underlying health concerns?

Has a member of your household been furloughed /lost their job?

Has a member of your household recently left the care system?

Have you experienced domestic abuse?

Are you or your partner under 18 years old?

GWHA may request that you submit proof to support your claim. These will be requested by email, screenshot, pictures or similar.