ESF1420: European Social Fund – Eligibility Self-declaration Form

Part 1: Participant Details (to be completed by the provider)
Participant name 
NI number            	
Telephone number                                                        Date of Birth 
Participant address      

Post Code                    

Part 2: Participant Eligibility (to be completed by the provider)
If the participant is Inactive, please state below how they meet the Inactive eligibility definition (as detailed in provider guidance): 
A)      	
                                                                                                                                                       Part 3: Eligibility self-declaration (to be completed by the participant or a representative, which can be the provider)
To be eligible for this provision you must be Unemployed or Inactive. The provider will explain to you what Inactive means. If you are currently Inactive please fully explain your situation below. This information needs to further explain the statement provided in box A:
B)	

Part 4: Participant Eligibility (to be completed by the provider)
Please state below the specific eligibility category/categories (as detailed in provider guidance) against which the participant is being referred:
C)	
                                                                                                                                                       Part 5: Eligibility self-declaration (to be completed by the participant or a representative, which can be the provider) 
Please provide an explanation below, of the barriers to work you have to support the reason you are being referred to ESF as stated in box C. For London Troubled Families provision participants this can include the barriers to work you and/or your family members have:    
D)	
                                                                                                                                                      (Only applicable to London Troubled Families provision participants)                            Please explain your family situation below, including information about your living arrangements, such as whether your family members live in your household and information on any dependent children and where they live:  
 E)	

Part 6: Participant Declaration (to be completed by the participant)                                                                                                                                                                                                                                                                                                                                           
The information I have provided is current and correct to the best of my knowledge and will be used by the provider named on this form to confirm that I can start on this provision.
Participant Signature    	          Date 
                                                                                                                                                       Part 7: Provider Details and Declaration (to be completed by the provider)
I certify the information given on this form is correct to the best of my knowledge for the individual named in Part 1:
Name of advisor/ tutor                                                                        Date       
Signature                            

Provider name                                                                     Contact Phone 

This completed form is not to be sent to DWP but must be securely held and easily retrievable and accessible with the participant records.