COVID 19 - SUPPORT GRANT
RATEPAYERS NAME ………………………………………………………………………………………..........................
BUSINESS PREMISES ADDRESS ………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………......
BUSINESS RATES ACCOUNT NUMBER …………………………………………………….……………....………………………….
VAT REGISTRATION NUMBER (if applicable) ……………………………………………………………………………………….
COMPANY NUMBER (if applicable) ……………………………………………………………………………………………………..
BANK ACCOUNT DETAILS
SORT CODE
ACCOUNT NUMBER
ACCOUNT NAME
DECLARATION
By signing this form I declare the following:
The information on this form is correct and complete to the best of my knowledge and belief. I
understand that it is a criminal offence to make a statement or representation that I know to be
incorrect or to provide documentation that is false or I fail to disclose information to the authority
where the law requires it, after this form is complete. If I do so I may be prosecuted. I understand
Halton Borough Council is under a duty to protect the public funds it administers and to this end
may verify the information I have provided on this form with other internal departments,
government agencies, local authorities and private sector organisations for the purpose of billing,
collection and recovery of business rates and for the prevention and detective of fraud. Halton
Borough Council may also share this information with these agencies and other bodies’
responsibilities for auditing or administrating public funds for these purposes.
NAME
SIGNATURE
DATE
TELEPHONE NUMBER
EMAIL ADDRESS
PRIVACY NOTICE: Halton Borough Council is the Data Controller for the personal information you
provide. You can view the full privacy notice at http://www.halton.gov.uk/privacynotices
**Please email the completed form to business.rates@halton.gov.uk in order
for your details to be processed**
dd mmm yyyy
click to sign
signature
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