Version 5

PLEASE COMPLETE ALL SECTIONS AND RETURN THIS FORM VIA E-MAIL IF POSSIBLE TO YOUR EARLY HELPINBOX : OR A HARD COPY BY POST TO :The Administrator, Cotswolds Families First,The Old School, Lewis Lane, Cirencester, Glos GL7 1EB Tel: 01452 328101

Have you registered a My Plan/My Plan +? A notification template form can be foundhere
(If no, the Request for Spend form cannot be processed) / Yes / No
Child’s Full Name: / Date of Birth:
Assessment Completion Date: / Date of Last Review:
Lead Practitioner Name
Lead Practitioner Contact Details (Address and phone number)
Lead PractitionerEmail address:
Total Spend to Date from 1 April this year: / £
Will this request take the cumulative spend from 1 April this year on this child over £350? (Delete as appropriate) / YES / NO
If YES, do you have agreement from your Team Around the Child (TAC)/Team Around the Family (TAF) / YES / NO / Not applicable
Date of TAC/TAF where spend was agreed:

Why the funding is required and what the expected outcomes are from using the funding?

(Copy this exactly from the My Plan/My Plan +)

Identified
Primary Need / Outcome / Type of Provision
Start & Finish Dates / Provider
Who is providing the service / Cost £ :
Please give the amount that you are requesting and ensure that the total spend is correct. / Other Contribution:-
Parent/Carer/
Charity/Other
Total spend for this request / £
Service Delivery Agreement: Are you commissioning a service/support/activity? / Yes/No
If Yes, please attach the Service Delivery Agreement (SDA) with the Request For Spend (RFS) Form. A SDA template can be found here
Please note, we will be unable to process your request if a Service Delivery Agreement is not attached.
PAYMENT DETAILS BOX:
Please tell us exactly how you want the payment to be madeby choosing from one of the following payment methods for each service below. You should allow up to 28days for all payments to be processed. Where possible use your own in-house processes to make payment and then the Fund Administrator – Cirencester Town Council will reimburse.
INVOICE – this would be the preferred method of payment wherever possible. Invoices must be made out to Cirencester Town Counciland sent to the Lead Practitioner who is then responsible for forwarding the invoice and the RFS form toCirencester Town Council, FAO Libby Hughes, Bingham House, 1 Dyer Street, Cirencester, GL7 2PPfor payment.
AMOUNT REQUESTED:£
Name of company:
Frequency of Invoice– One-off / Monthly / Other please state
(Delete as appropriate)
CHEQUE - Cheques can be raised and made payable to any family member or to a supplier that cannot be invoiced (eg. a shop). Please note that cheques will only be sent to Lead Practitioners.
AMOUNT REQUESTED:£
Cheque made payable to:
Payee’s address:
LP’s name & address to post cheque to if different from above:
CASH – Cash requests can be processed for collection from one place, with a cash limit of £50.00 per request. You will be contacted when the cash is ready.
AMOUNT REQUESTED:£
Libby Hughes Cirencester Town Council, Bingham House, 1 Dyer Street, CirencesterGL7 2PP
Will this payment be made direct to the family? ( If yes, please ensure that you obtain a signed receipt of the monies) / YES/ NO
Electronic signature of Lead Practitioner: / Date:

If you are sending this form by e-mail, YOU MUST type your name into the signature box and send it from YOUR
e-mail address.

For admin purposes only
Check and returned for payment by: / Name:
Date: