Digital inclusion scheme application form

Before applying for the digital inclusion scheme, please read full details about who is eligble and what we can provide here:

How to apply:
  • Fill out the application form below, upload the required documents and click submit.
How did you find out about the Digital Inclusion Scheme? (Tick all that apply):

Do you have any dependents?:

Do you receive Income Support, Universal Credit or Employment Support Allowance?:

Do you receive any other state benefit?:

Do you earn under £10.75 per hour?:

Are you currently:

Have you been accepted to a course?:

Do you have a smart phone?:

How do you currently connect to the internet?:

How would you rate your IT skills?:

Do you currently access any Origin services online?:

6. Tick the items you are applying for:

If you are applying for data, will you be able to maintain internet access after the data awarded is used up? :

I certify that the above information and financial details provided are correct and complete and show my income from all sources:

I agree to notify the Employment & Training coordinator of any change in my circumstances which may affect my eligibility for the award as soon as this occurs and I understand that failure to do this may mean that Origin Housing may request the return of equipment:

I understand that Origin will reclaim the equipment if I have given misleading or inaccurate information intentionally. I recognise that false statements can leave me open to prosecution:

I understand I can only present one application per household :

I understand that Origin Housing reserves the right to review and adjust my application:

I will be willing provide feedback on how the equipment has made a difference if my application is approved:

Before submitting your application, please make sure you have filled out all sections on this checklist:

Security code: