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Supported Lodging Scheme
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Expense Claim & Record
For SCAH office use only: SCAH reference/ Bank reference:
Request for Support
- please complete and submit the form below:
Indicates required field
Name of Referrer
Organisation/ phone number of Referrer
Email of referrer
Beneficiary's family surname or main contact's initials
Beneficiary's postal code:
Gender/ Age/ Ethnicity of beneficiary
Additional needs /Disability: YES/NO
Who else lives with the family/beneficiary e.g. daughter, partner, sister etc?
Relationship to main family contact/beneficiary e.g. son, daugher etc?
Gender/Age (e.g son/aged 7) ?
Disability (if 'yes', please give brief details
How will a Starter Pack help this family/beneficiary?
FOR SCAH OFFICE USE ONLY: Name of shopper/ Cost of items/Date expenses claimed
SCAH Registered Charity No: 1058279