Family - Legal Aid – University House

Name *

First

Last

Email *

Address *

Postcode *

Phone Number

Preferred Contact Method *

Telephone
Email

Please confirm whether or not you are in receipt of the following welfare benefits? *

If you are not in receipt of any of the above welfare benefits, please confirm your annual household income.

Do you have any long-term health conditions or disabilities? *

Yes
No

How many adults live in your household? *

How many children live in your household? *

Housing Status *

Please note, we are unable to assist leaseholders or owner occupiers with any issues relating to their property.

Advice

Legal Area *

Housing Enquiry Area *

Who is your landlord? *

Other party's full name *

Other party's postcode *

Has there been any domestic violence issues within the household or former relationship?

Yes
No

Has there been any police involvement?

Yes
No

If you are employed or self-employed, what is your monthly or annual income?

Please provide the gross amount (i.e. before tax)

What type of benefit matter do you need assistance with? *

Employer's Name *

Which borough is your employer based? *

Job Title *

Are you a member of a trade union? *

Yes
No

Date employment started *

Wage/Salary *

Employment Status *

Hours worked *

Date employment terminated (if applicable)

Do you have any insurance? (e.g. household, motor, mobile phone) *

Yes
No

Do you have any deadlines to meet or hearing dates?

What is the reason you are seeking advice? *

Dismissal
Disciplinary
Grievance
Disability/Sickness

Have you appealed a Benefit decision to the Tribunal? *

Do you have the appeal bundle? *

If you have a Tribunal hearing date and time, please enter it here.

Date

Time

Brief description of the issue you are seeking advice on *

Name of referral organisation (if applicable)

I confirm I have read University House Legal Advice Centre's privacy policy and I give consent for them to store my personal details submitted by this form. I am aware that I can withdraw my consent at anytime. *

I agree

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