1 2013/14 Housing Benefit and Local Council Tax Support claim form Don t delay - claim today! Please return this form as quickly as possible, even if you do not have everything we ask for. can send the rest to us later. Filling in the form Use blue or black ink to fill in the form. Do not use pencil. If you make a mistake, just cross it out and put the right answer next to it. Do not use correction fluid or tape. Please initial any alterations. Answer or questions by ticking the relevant box. If you are picking an answer from a list of answers, put a tick in the relevant box. Do not put a cross in any boxes. If you answer a question with a cross or do not answer a question we will have to send the form back, and this will delay the claim. If someone else fills in the form for you, there is a special space for them to sign in Part 15. must sign Part 15 as well. If you need help filling in this form, please phone and ask for the Benefits Section, or you can call into the Council Offices at the address below. If you cannot get out easily and need help filling in the form, we can come and help you. Please phone Please send the form back to us straight away to make sure you do not lose any benefit. r benefit will normally start from the Monday after we receive the form. In the form, we ask for proof of your income, rent and so on. If you don t yet have all the proof we need, send the form in now and send the proof later. have one month from the date we receive the form to send in the proof. must tell us immediately if your circumstances change. See page 2 for a list of changes that may affect your claim. Please return the form either by post to: Benefit Section, Hertsmere Borough Council, Civic Offices, Elstree Way, Borehamwood, Herts WD6 1WA Or in person by visiting the Civic Offices: Monday to Thursday 8.30 am pm Friday 8.30am pm Hertsmere Borough Council, Civic Offices, Elstree Way, Borehamwood, Herts WD6 1WA Phone:
2 tes for filling in the claim form About this form The Housing Benefit and Council Tax Support claim form has been specially designed to be easy to fill in. It is long, but we have to ask a lot of questions to make sure that everyone who claims gets the right amount of benefit. may not have to fill in all parts of the form, but you must fill in any part that is relevant to you. Every part starts with a question to help you decide if you need to fill in that part. Second Adult Rebate Second Adult Rebate is a reduction in your Council Tax you can get if you share your home with someone who is not your partner, is on a low income, is 18 or over, and is not liable to pay you rent. If you are claiming Second Adult Rebate, only fill in Parts 1, 3, 13 and 15. Evidence We need to see evidence of some of the things you tell us about. The checklist at the end of the form will help you. If you are not sure if we need to see evidence of something, get in touch with us. We will tell you what we need to see. We cannot pay you benefit until we have seen the evidence we have asked for. How we collect and use information We will use the information you give in this form, and in any supporting evidence you send us, to process your claim for Housing Benefit, Council Tax Support and other Welfare Benefits. We may pass the information to other agencies or organisations such as the Department for Work and Pensions and HM Revenue and Customs, as allowed by law. We may check information you have provided, or information about you that someone else has provided, with other information we hold. We may also get information about you from certain third parties, or give them information, to: make sure the information is accurate; and prevent or detect crime; and protect public funds. These third parties include government departments, local authorities and private-sector companies such as banks and organisations that may lend you money. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to. page 2 The Council is the data controller for the purposes of the Data Protection Act. If you want to know more about what information we have about you, or the way we use it, please ask us. If we award you Housing Benefit or Council Tax Support If you are awarded Housing Benefit or Council Tax Support, we may review your claim regularly. This may involve an unannounced visit to your home by our Visiting Officer. We may also post you a form that you should complete and return to us with all relevant supporting evidence. Changes you must tell us about Tell the Council's benefits section straight away if; or any member of your household cease to be entitled to Job Seekers Allowance, Income Support or Employment Support Allowance for any reason; or any of your children leave school or leave home; or anyone moves in or out of your home (including lodgers, joint tenants and subtenants); or your income or the income of anyone living with you, including benefits, changes; or your capital, savings or investments change; or you or anyone living with you becomes a student; goes on a th Training Scheme; goes into hospital or a nursing home; goes into prison; or gets, changes or leaves a job; or your rent changes; or you move house; or you or your partner are going to be away from home for more than a month; or you receive any decision from the Home Office; or anything you have told us about changes; or you or any member of your household is awarded or ceases to be entitled to Disability Living Allowance or a Personal Independence Payment. must tell us about these changes in writing a phone call is not enough. If you don t tell us about these changes, you may lose money you are entitled to or you may get too much benefit. must make sure that you tell us about these changes. Don t rely on someone else to pass on the message. It is an offence not to tell us about any change of circumstance that affects your benefit. We may take court action against you. If we pay you too much benefit, in most cases, you will have to pay it back.
3 page 3 Important Before completing this form, please read and sign the following statement: By completing this claim form I give an undertaking that the information I declare is, to the best of my knowledge, accurate and complete. I understand that I give information that is incorrect or incomplete the Local Authority may take action against me, including prosecution in Court. I have read and understood this declaration: Signed Office use only If you are just claiming Second Adult Rebate, only fill in Parts 1, 3, 13 and 15 of this form. Part 1 About you and your partner Do you have a partner who normally lives with you? A partner means a person you are married to or have a civil partnership with, or a person you live with as if you were their husband, wife or civil partner. (A civil partnership is a formal arrangement that gives same-sex partners the same legal status as a married couple.) Even if your partner only comes home at weekends, or part of the week,you must include them Surname or family name Other names Any other surnames or family names you have used, such as before marriage or in a previous marriage Title (Mr, Mrs, Ms and so on) Address Do not tell us your partner s address if it is the same as yours. If you have a partner, you must answer all the questions about them, as well as yourself. r partner What date did you move in to this address? (first spent the night there) r daytime phone number do not have to tell us this, but it may help us to deal with your claim more quickly. What is this number? Please tick. address We want to deal with your claim as quickly as we can and if we have your address we may contact you this way. Date of birth National Insurance number can find this on payslips or letters from social security or the tax office. We can decide your claim only if we see evidence that this is your National Insurance number (see part 16). Home Work Mobile Textphone Home Work Mobile Textphone Letters Numbers Letter Letters Numbers Letter If you do not have a National Insurance number tick this box. If your partner does not have a National Insurance number tick this box. We must see evidence of you and your partner s identity and National Insurance number. If you or your partner are asylum seekers, you must provide your current Home Office letter. Read the checklist in part 16.
4 Part 1 About you and your partner continued page 4 Are you living away from home at the moment? Tell us why you are not living at home. When did you last live at home? When do you expect to go back home? Tell us the address where you are living at the moment. If your home has been sublet, tell us who lives there now. Have you or your partner claimed Housing Benefit, Council Tax Benefit or Council Tax Support before? r partner When did you claim? When did they claim? Which council did you claim from? Which council did they claim from? What name did you claim in? What name did they claim in? What address did you claim for? What address did they claim for? Please provide your previous address. Were you the home owner, a private tenant, a council tenant or a boarder at this address? Have you or your partner come to live in England, rthern Ireland, Scotland, Wales, the Republic of Ireland, the Channel Islands or the Isle of Man in the last 2 years? We will write to you about this. We will write to you about this. What is your nationality? If your nationality is not British, on what date did you last enter the UK? The UK is England, rthern Ireland, Scotland and Wales.
5 Part 1 About you and your partner continued page 5 Are you or your partner in hospital at the moment? Do you or your partner get Disability Living Allowance? Do you or your partner get a Personal Independence Payment? Do you or your partner get Attendance Allowance? Does anyone get Carer s Allowance for looking after you or your partner? Have you or your partner ever claimed Carer s Allowance or Invalid Care Allowance? Still tick if you claimed but were not paid any money. Do you or your partner receive overnight care from a non-resident carer? If '', tell us the name and address of the person or organisation providing the care. When did you go in? When will you come out (if you know this)? Name: Address: r partner When did they go in? When will they come out (if they know this)? Name: Address: How often do they stay overnight? Do you or your partner have a vehicle from a mobility scheme? Are you or your partner a student? Do you study full time or part time? Do they study full time or part time? Tick if you or your partner are: an apprentice on youth training in legal custody severely mentally impaired registered blind long-term sick or disabled Full time Part time Full time Part time Is anyone in the household pregnant? If, who? Due Date
6 Part 2 About children may be able to get more benefit if there are children in your household and they are: under 16; or aged 16 to 20 and in full-time further education or approved training. page 6 Are there any children in your household? Go to Part 3. If there are more than 4 children, use a separate sheet of paper to tell us all the information we ask for on this page. Surname or family name Other names If you are sending a separate sheet of paper, tick this box. First child Second child Third child Fourth child Date of birth What is the child s sex? The child s relationship to you The child s relationship to your partner Usual address if different from yours Child Benefit number Who gets the Child Benefit for them? We need to see proof of this. Is the child registered blind? Does this child get Disability Living Allowance or a Personal Independence Payment? Are they unable to share a bedroom because of their disability? Do you pay a registered childminder, nursery or after-school club any childminding costs for this child? First child Second child Third child Fourth child If yes, please tell us the If yes, please tell us the If yes, please tell us the If yes, please tell us the name and registration name and registration name and registration name and registration number of the childcare number of the childcare number of the childcare number of the childcare provider. provider. provider. provider. How much do you pay a week? How much do you pay a week? How much do you pay a week? How much do you pay a week?
7 Part 3 About other people who live with you page 7 Do any adults usually live with you and any partner you have? Go to Part 4. Answer all questions in this section. By adults we mean people over 16 who nobody gets Child Benefit for. Do not tell us about people who just share a hall, bathroom or toilet with you. w tell us about all the people who usually live with you and your partner. If you want to tell us about more than 3 people, use a separate sheet of paper. If you are sending a separate sheet of paper, tick this box. First person Surname or family name Other names Second person Third person Date of birth National Insurance number. do not have to tell us this, but it may help us to deal with your claim more quickly. Their relationship to you or your partner Some examples are aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint owner, subtenant, lodger or friend. When did they move in? Letters Numbers Letter Letters Numbers Letter Letters Numbers Letter Do they get Income Support, income-based Jobseeker s Allowance, Pension Credit or Employment and Support Allowance (income-related)? Do they get Disability Living Allowance, Attendance Allowance or a Personal Independence Payment? Are they registered blind? Are they a full-time student, a student nurse, a care worker, an apprentice or on youth training? Tell us which. Tell us which. Tell us which. Are they currently serving in the armed forces? Do they pay rent or money for board and lodgings to you or your partner? How much? a week How much? a week How much? a week Are they severely mentally impaired?
8 Part 3 About other people who live with you continued page 8 Are Sthey in legal custody at the moment? Are they in hospital at the moment? Do they normally work for 16 hours or more a week? FFirst person When are they expected to be released? When are they expected to be released? When are they expected to be released? When did they go in? When did they go in? When did they go in? When will they come out (if you know this)? When will they come out (if you know this)? When will they come out (if you know this)? Second person Tell us their earnings Tell us their earnings before any deductions. before any deductions. Third person Tell us their earnings before any deductions. Do they have any other income? This includes any benefits, allowances, tax or pension credits you have not told us about on this form and interest from savings and investments. First other type of First other type of First other type of income income income How much is it before deductions? a week Second other type of income How much is it before deductions? a week Second other type of income How much is it before deductions? a week Second other type of income How much is it before deductions? a week Third other type of income How much is it before deductions? a week Third other type of income How much is it before deductions? a week Third other type of income How much is it before deductions? a week How much is it before deductions? a week How much is it before deductions? a week Are any of the people who live with you married to each other, civil partners of each other, or living together as if they are married or civil partners? Tell us their names. And is the partner of is the partner of We must see evidence of all income and interest from savings for the people shown above. Read the checklist in Part 16.
9 Part 4 About rent page 9 Do you rent your home? Tick if you would pay rent but already get Housing Benefit. Go to Part 6. Answer all the questions in this section. How much is the rent for your home? every (For example, every week/fortnight/4 weeks/month) What date did your tenancy start? May we discuss the progress of your claim with your landlord? We will not disclose personal/income information. Please sign here. I authorise the Council to discuss the progress of my claim with my landlord. Signed Date What is your landlord s name and address? By landlord we mean the person or organisation who owns the property you live in. If your landlord has an agent, tell us their full name and address. By agent we mean the person or organisation you actually pay your rent to. Are you, your partner, or any of your or your partner s children related to your landlord or agent, or to your landlord s partner or the agent s partner? Related includes related through marriage, even if the marriage has ended. Some examples are exwife, ex-husband, aunt, brother, daughter, father, grandson, grandmother, son-in-law or stepdaughter. Are you or your partner a director, shareholder or employee of your landlord? Have you or your partner owned your current home in the last 5 years? What is the relationship? is my landlord s or agent s Does anyone else share the rent with you and your partner? Tell us their names and their relationship to you and your partner. How much of the rent do you pay? every (For example, every week/fortnight/4 weeks/month)
10 Part 4 About rent continued page 10 Has your rent been registered as a fair rent by a rent officer? Don t know Are there any weeks when you do not have to pay rent? How many in a year? Are you behind with your rent? By how many weeks? Does your rent include money for the following? Meals Which meals are included? All Breakfast Evening Water authority charges Heating Lighting Hot water Fuel for cooking What is it? Is anything included or separate from your rent that you have not already told us about? Part 5 About where you live What sort of building do you live in? Tick one box only. Detached house Flat in a house Caravan, mobile home or houseboat Semi-detached house Flat in a block Board and lodgings Terraced house Flat over a shop Hotel Maisonette Bedsit or rooms Residential nursing home Bungalow Hostel Residential care home Detached Bungalow Other (please say what) a H
11 Part 5 About where you live - continued page 11 How many rooms are there in the building? Living rooms Bedsitting rooms Bedrooms Bathrooms or shower rooms Separate toilets Kitchens Other rooms In the whole Just for you and That you share with building? your household? other people? What are these other rooms? Do you use your home for business purposes? Are you or your partner a registered Foster Parent? Do you have a main home somewhere else? If your main home is somewhere else in the UK or abroad, tick, even if you do not pay rent for it. What is the address? Part 6 About Income Support, income-based Jobseeker s Allowance, Pension Credit (Guaranteed Credit) and Employment and Support Allowance (income-related) Are you or your partner getting Income Support, income based Jobseeker's Allowance, Pension Credit (Guarantee Credit) or Employment and Support Allowance (income related) at the moment? Are you or your partner still waiting to hear about a claim for Income Support, income-based Jobseeker s Allowance, Pension Credit (Guarantee Credit) or Employment and Support Allowance (income-related)? When did you start getting it? When did you claim? r partner When did they start getting it? When did they claim?
12 Part 7 About benefits, tax credits and state pensions page 12 Are you or your partner getting any of the benefits or credits listed below, or are you waiting to hear about benefits or credits you have Go to Part 8. claimed? Read the list of benefits and credits below and tell us about any that you or your partner are getting now or have claimed. Please Tell us about the benefits below. put a line through any boxes that do not apply to you or your partner. We will need to see evidence of the benefit or credit, such as an award letter. r partner How much How often How much How often Pensions do you get? is it paid? do they get? is it paid? State retirement pension Pension Credit (Savings Credit) Widow s Allowance or Bereavement Allowance Widowed Parent s Allowance or Widow s Pension War Widow s or War Dependant s Pension War Disablement Pension Industrial Injury/Disablement Pension Exceptionally Severe Disablement Allowance Benefits and allowances Contribution-based Job Seeker s Allowance Child Tax Credit Working Tax Credit Employment Training Allowance Child Benefit Employment and Support Allowance - contribution based Attendance Allowance Disability Living Allowance: Mobility Component Care Component Carer s Allowance Severe Disablement Allowance Maternity Allowance Fostering Allowance Personal Independence Payment Universal Credit Any other benefit, pension or money from the government Are you repaying a Social Fund loan or overpayment for any of these benefits? Have you or your partner deferred (put off) receiving a pension? Incapacity Benefit If yes, which one? If yes, please give details
13 Part 8 Income other than earnings page 13 Do you or your partner have any money coming in (or expect to have some money coming in) that you have not already told us about on this form? do not need to tell us about payments from the Independent Living Fund, the Eileen Trust or the Macfarlane Trust. How much How often Private Pension 1 paid by do you get? is it paid? Go to Part 9. Answer the questions on this page. Please put a line through any boxes that do not apply to you or your partner. r partner How much How often do they get? is it paid? Private Pension 2 paid by Date of next increase Date of next increase Date of next increase Pension Protection Fund Payments Date of next increase th Training Scheme payment or Training Credits Maintenance for you Maintenance for your child - including CSA Student grant or loan Payments from boarders Weekly amount from letting or subletting a property or part of a property Payments from a charity Any other income e.g. Redundancy or Loan Protection Payments (please give name) We must see evidence of any money or pension coming in before we can decide how much benefit you can get. Read the checklist at Part 16 to see what you can use as evidence. Part 9 About working for an employer Do you or your partner work for an employer? Do you work for more than one employer? What kind of work do you do? Go to Part 10. Answer the questions in this part. Tell us about all the employers on a separate sheet of paper and send it with this form. Include all the information asked for below. If you are sending a separate sheet of paper, tick this box. r partner Go to Part 10. Answer the questions in this part.
14 Part 9 About working for an employer - continued page 14 What is your employer s name and address? r partner When did you start this job? How much do you get paid before tax and National Insurance are taken off? How often do you get paid? Every Every How are you paid? For example, in cash, by cheque or straight into a bank or building society account. How many hours a week do you usually work? Give details of any regular overtime, bonuses, commission or tips. Are you getting Sick Pay, Maternity Pay, Paternity Pay or Adoption Pay from your employer at the moment? When did it start? Do you pay into a private or company pension scheme? How much? How often? Every How often? Every How much? We must see 5 weekly, 3 fortnightly or 2 monthly consecutive payslips before we can decide how much benefit you can get. Read the checklist at Part 16 to see what you can use as evidence. Part 10 About being self-employed Are you or your partner self-employed or the director of a limited company? Go to Part 11. Answer the questions Go to Part 11. Answer the questions on this page. on this page. must send us your trading accounts for the last financial year. If you have only recently set up the business and do not have a full year s accounts, we will need to see some other evidence of your income. We will write to you about this. r partner r partner What kind of work do you do?
15 Part 10 About being self-employed - continued page 15 r partner When did the business start? What is the business address? Are you a Director of the business? Are there any other partners in the business? Tell us their name and address. Tell us their name and address. How many hours a week do you usually work? Do you get a Business Start-up Allowance? How much? How often? How often? Every Every How much? Do you pay into a private pension scheme? How much? How much? How often? How often? Every Every We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist at Part 16 to see what you can use as evidence. Part 11 About any other work Do you or your partner do Go to Part 12. any other work? This could be voluntary work, Answer the questions on therapeutic work or any other this page. work. Go to Part 12. r partner Answer the questions on this page. What other work do you do? What is the name and address of the person you do this work for?
16 this work for? Part 11 About any other work - continued r partner page 16 When did you start this work? What is the name and address of the person you do How this work many for? hours a week do you usually work? Do you get paid for this work? How much? How much? When did you start this work? How many hours a week do you usually work? How often? How often? Every Every D We must see evidence of any earnings before we can decide how much benefit you can get. Read the checklist at Part 16 to see what you can use as evidence. Part 12 About bank accounts, savings, investments and property Do you or your partner have any bank We must accounts, see savings, evidence property of any earnings before we can decide how much benefit you can get. or Read investments the checklist in the at UK Part or abroad? 16 to see what you can use as evidence. This includes cash, current accounts and savings accounts Answer all the questions in this part. We must see evidence of all the capital, savings with a bank or building society, and investments that you and your partner hold. Read the checklist at Part 16 to see post office accounts, premium what you can use as evidence. bonds, National Savings We will need statements or passbooks covering the last 2 months at least. Certificates, stocks, shares and property. r partner Please answer these questions for yourself and your partner. Please include empty and overdrawn accounts, whether in one name or jointly held with anyone else. r Partner's Account number/name/other details balance/value balance/value Do you have bank, building society or post office accounts? (including current accounts) If yes, please give details. Name Number held Do you have stocks, shares, unit Part trusts? 12 About bank accounts, savings, If yes, list the names of investments and investments number of and property - continued shares held. Do you have National Savings Certificates? If yes, list the issue, purchase date and number of units. page 17 Do People you have who have other more than 16,000 in capital are not normally entitled to receive Housing Benefit or Council investments, Tax Support redundancy (although special rules apply to people in receipt of the Guaranteed element of Pension Credit). payments, Capital includes premium money, bonds, savings, property and land held either in the United Kingdom or abroad. Tessas, ISAs, SAYE, cash etc?
17 page 18 Part 14 Anything else you need to tell us Use the box below to tell us anything else you think we should know about. Use a separate sheet of paper and Do you have National Part Savings 12 Certificates? About bank accounts, savings, If yes, list the issue, purchase investments and property - continued date and number of units. Do Do you you have have National other Savings investments, Certificates? redundancy If payments, yes, list the premium issue, purchase bonds, date Tessas, and ISAs, number SAYE, of cash units. etc? If yes, please give details. Do (Please you also have use other this space if investments, you need to tell redundancy us more about payments, premium bonds, any of the above savings.) Tessas, ISAs, SAYE, cash etc? If Have yes, you please or your give details. partner (Please also use this space if received any backdated you benefit need or to deferred tell us more about any payments, of the above such as savings.) State pension, which you have added to your savings? Do you or your partner own or partly own any property or land except the home you live in, either in the UK or abroad? Tick, even if you have a mortgage or loan for the property or land. This includes jointly owned properties. If please give details. What is the address? page 17 How much is it worth? If you have a mortgage or loan for this, how much is left to repay? Have you or your partner received a compensation payment relating to the Second World War? Part 13 Backdating We can usually award Housing Benefit or Council Tax Support from the Monday after the date we get your claim. Sometimes we can pay Housing Benefit or Council Tax Support from an earlier date if you have a good reason for not claiming earlier. If you want us to consider paying your claim from an earlier date, tell us when you want Housing Benefit / Council Tax Support from and why you did not claim before. Tell us the date you want to claim from. Tell us all the reasons why you could not claim before today.
18 page 18 Part 14 Anything else you need to tell us Use the box below to tell us anything else you think we should know about. Use a separate sheet of paper and attach it to this form if you need to. If you are sending separate sheets of paper with this form, tell us how many. Part 15 Declaration page 19 Part 15 Declaration page 19 Even if someone else has partly or fully filled in this form for you, you MUST sign this declaration if you can. If you have a partner, it would be helpful if they sign below to confirm that all the details about them are correct. Please read this declaration carefully before you sign and date it. I understand the following: If I give information that is incorrect or incomplete, you may take action against me. This may include court action. will use the information I have provided to process my claim for Housing Benefit or Council Tax Support or both, or to assess any discount or grant for Council services. may check the information with other sources as the law allows. may use any information I have provided for this and any other claim for social security benefits that I have made or may make. This includes any Discretionary Housing Payment. may give some information to other government organisations, such as government departments and local councils, if the law allows this. The council may share data with the government in order to combat fraud and reduce error and this includes the use of tracing agents. I know I must let the Council's Benefit Section know immediately in writing about any change in my circumstances or the circumstances of anyone living with me, which might affect my claim. If I do not, you may take action against me This may include court action. I declare that this is my claim for Housing Benefit and/or local Council Tax Support and the information I have given on this form is correct and complete. I authorise the Council to make any necessary enquiries to check that the information is true and correct. I have read and understood this declaration, and my responsibilities in reporting any changes in my circumstances to the Council. Signature of person claiming Date Partner s signature Signature of person claiming Date Date
19 Part 15 Declaration - continued Date page 19 If this form has been partly or fully filled in by someone who is not the person claiming, please tell us why you are filling in this form for the person claiming. As far as possible, I have confirmed with the person claiming that the answers I have written on this form are correct. If I am making this claim on behalf of the above person, I understand that I am liable for what I have written on the form and accept that the declaration applies to me. Name of the person who filled in the form Signature of the person Relationship to the person claiming Date Part 16 Checklist Please tick to tell us what evidence you are sending with this form. We must see original documents, not copies. If you bring them to our reception, we will take the details we need and give you the documents back straight away. If you do not provide all the evidence we need, we might not be able to pay you any benefit. We need the same evidence for your partner, if you have one, and for any other adults living in your home. If you cannot send the evidence we need at the moment, send the form back to us now and send the evidence later. We can start to process your claim, but we will not be able to pay you any benefit until we have all the evidence. Please tell us now in Part 14 if you cannot supply the evidence within one month. Evidence of identity Such as a birth certificate, marriage certificate, passport, National Insurance number card, medical card, driving licence, UK residence permit, current Home Office letter, EU identity card or recent gas or electricity bill. We may need to see several of these documents for each person. Evidence of National Insurance number Such as a National Insurance number card, payslips or letters from social security or the tax office. Evidence of savings, investments and property Such as all your bank, building society or post office books, full bank statements, or certificates for premium bonds, National Savings Certificates, ISAs, Tessas, stocks, shares and unit trusts. The evidence you send must show details for at least the last 2 months. Evidence of earnings This means your last 5 payslips if you are paid every week, your last 3 payslips if you are paid every 2 weeks, or your last 2 payslips if you are paid every month. We can send a form to your employer to fill in if you do not have these payslips. If you or your partner are self-employed, we need to see your accounts for the last financial year or, if you have been trading for less than 6 months, a summary of your trading records so far. We can supply a form. Evidence of other income Such as pension slips from a former employer or a letter from the court showing how much maintenance you are getting. We need to see evidence of any money people pay you for board and lodgings. Evidence of benefits, allowances, tax credits, pension credits or pensions Such as current award notices or letters from the Department for Work and Pensions confirming how much you get. If you do not have evidence, let us know straight away. Evidence of private rent and tenancy Such as a rent book, rent receipts, a tenancy agreement or a letter from your landlord, or we can supply a form. Evidence of other money paid out Such as letters about student grants or maintenance, or agreements or receipts from registered child carers.
20 Part 17 Equal Opportunities page 20 The government has asked us to gather information about our customers ethnic background. It s your choice whether to fill in this section. Please show which of the following groups you and your partner (if any) consider you belong to by ticking one box for you and one for your partner. White r partner Asian r partner British Irish Other white Mixed White and black Caribbean White and black African White and Asian Other mixed Asian British Bangladeshi Indian Kashmiri Pakistani Other Asian Black Black British Caribbean African Other black Chinese Sexual orientation Other Bisexual Gay Heterosexual Lesbian Prefer not to state Religion Religion is any religion, religious belief, faith or similar philosophical belief Christianity Muslim Hindu Buddhist Jewish Sikh Religion Other If Other please state Part 18 How you will be paid and the choices you have. If you are awarded council tax support we will credit this to your council tax account. If you pay rent to a private landlord we will pay any benefit directly to you. If you feel this will cause you difficulties, please ring for a Direct Payments to Landlord form If you pay rent to a Housing Association you can either have your housing benefit paid to you or direct to your Housing Association Please tick how you would like to be paid To myself Name of bank/building society To my Housing Association Payment to you or your landlord will be made by direct credit to a current or basic bank account. Please complete the details of the account to be credited. Branch Account name Account number Sort code r signature: Please pay any Housing Benefit I may be entitled to by the method I have ticked. I understand that once I have selected a payment method, the Council cannot change it without written instructions. I understand that if payments go to my landlord or agent, they must agree in writing to any change. If you have not got a current or basic account, and have previously been unable to open one, banks have leaflets giving details of the new Basic Bank Accounts you can open. With a Basic Bank Account you will receive a cash-machine card, which you can usually use to draw cash in post offices, but not a debit card, cheque book or overdraft. How did you hear about Housing Benefit/ Council Tax Support?
2012/13 Please use capital letters Name Address Housing Benefit & Council Benefit Claim Form Don t delay - claim today! Do not delay returning this form if you do not have all the information that is asked
Housing Benefit and Council Tax Reduction Change of Address form. Name Address Don t delay claim today! Please return this form as quickly as possible, even if you do not have everything we ask for. You
Housing benefit and council tax benefit claim form It is important that you send your completed form now. You can send any information you have not included later, but we must receive it within one month
Housing Benefit and Council Tax Support (reduction) Claim Form Don t delay - claim today! Please return this form as quickly as possible, even if you do not have everything we ask for. You can send the
2014/15 Local Council Tax Support and Housing Benefit Claim Form Don t delay - claim today! Please return this form as quickly as possible, even if do not have everything we ask for. can send rest to us
Claim form for Housing Benefit and Council Tax Reduction If you are just claiming Second Adult Rebate, only fill in Parts 1, 3 and 15 of this form and tick this box. Part 1 About you and your partner Do
Town Hall Darlington DL1 5QT Phone: 01325 388514 Fax: 01325 388374 E-mail: HBEnquiries@darlington.gov.uk For office use only Housing Benefit reference number Date form requested Return by Issued by UPRN
HCTB1 notes 05/06 Housing Benefit and Council Tax Benefit tes for filling in the claim form for Housing Benefit and Council Tax Benefit About this form About Housing Benefit and Council Tax Benefit Second
2014/15 Council Tax Support and Housing Benefit Claim Form Don t delay - claim today! Please return this form as quickly as possible, even if you do not have everything we ask for, to make sure that you
Housing Benefit claim form Application form for the Local Council Tax Reduction Scheme Filling in the form If you are just claiming Second Adult Reduction, only fill in Parts 1, 3, 16, 17 and 18 of this
Please tell us your full name and address. r title (Mr, Mrs, Miss and so on) r last name A claim form for Housing Benefit and Council Tax Benefit Ashfield District Council, PO Box 5752, Kirkby in Ashfield,
A claim form for housing benefit and council tax benefit Isle of Wight Council Offices, Broadway, Sandown, PO36 9EA Tel: (01983) 823950 Name, address and postcode For official use only Hb ref: Date received
Benefits Section Town Hall The Parade EPSOM Surrey KT18 5BY Tel: 01372 732269 Name: Address: OFFICIAL USE ONLY Ben Ref: Date requested: Date issued: Claim type: A claim form for Housing Benefit and Council
For Office Use Only Ben Ref o: Date of Issue: Reason for Issue: Receipt Stamp HOUSIG BEEFIT, COUCIL TAX BEEFIT AD SECOD ADULT REBATE CLAIM FORM ou should complete and return this form as soon as you can.
Housing Benefit and Council Tax Reduction Scheme Claim Form District Council Title (Mr, Mrs, Miss, Ms) Surname/Family Name First Names Address Benefit Reference (if claimed at South Oxfordshire or Vale
Claim for Council Tax Support and Housing Benefit Do not fill out this form until you have read these notes. After you have read and understood them, remove the notes by tearing along the perforated line.
Housing Benefit claim form Application form for the Local Council Tax Reduction Scheme Filling in the form If you are just claiming Second Adult Reduction, only fill in Parts 1, 3, 17, 16, 18 17 and 19
Application for Housing Benefit or Council Tax Support (or both) Director or Finance and Corporate Services, Civic Centre, Neath SA11 3QZ For benefit enquiries relating to the Neath Borough and Upper Lliw
Herefordshire Council Claim form for Housing Benefit, Council Tax Reduction and free school meals Crystal Mark 9252 Do not write in this box it is for office use only. Date form sent out: Form to be returned
Benefits Section Pippbrook Dorking Surrey RH4 1SJ Tel: 01306 879187 Fax: 01306 879395 Email: firstname.lastname@example.org Name: Address: OFFICIAL USE ONLY Ben Ref: Date requested: Date issued: Claim type:
Please read the benefit information booklet supplied with this form before completing your claim Keep it safe as you may need to refer to it in future or translated into another language please call us
Please read the benefit information booklet supplied with this form before completing your claim Keep it safe as you may need to refer to it in future or translated into another language please call us
A CLAIM FOR DISCRETIONARY HOUSING PAYMENTS (DHP) Claim Ref: SECTION 1 INFORMATION If you are getting Housing Benefit and Local Council Tax Support but you are still having problems meeting your rent and
Application Form Housing Benefit Council Tax Reduction Alternative Council Tax Reduction This form can be made available in other languages and formats (including large print, audio tape and Braille as
Housing Benefit and Council Tax Support claim form www.merton.gov.uk/benefits Filling in the form Answer or questions by putting a tick in the relevant box. Do not put a cross or miss out any questions
Claim_rev 39 17/9/09 22:22 Page 1 Housing Benefit and Council Tax Support Claim form Do not write in this box. It is for office use only. Date of issue: Version: Sept 2009 Office receipt date stamp Please
Date of first contact Date of issue Applicants name Issuing officers signature Claim reference number FOR OFFICE USE ONLY Please return this form to: Benefits Team PO Box 4 Lancaster LA1 1QR Tel: (01524)
For office use only Reference Date issued Date received stamp Housing Benefit and Council Tax Support application form If you want to claim help with paying your rent or Council Tax, please fill in this
Benefits Service Benefits Service PO Box 1, Town Hall, Ripley PO Derbyshire, Box 1, Town East Hall, Midlands, RipleyDE5 3BT Derbyshire, Phone: 01773 East 841470 Midlands, DE5 3BT Phone: Fax: 01773 01773
Cambridge City Council Revenue Services (Benefits) FREEPOST PO Box 130 Cambridge CB2 1BR Tel (01223) 457721/86, 457693/97 Email: email@example.com Website: www.cambridge.gov.uk Thank you for downloading
HB&CTB-20ppForm-11Dec09-PM:Layout 1 11/12/2009 16:49 Page 1 H o u s i n g B e n e f i t a n d C o uncil Ta x R e d u c t i o n a p p l i c a t i o n form Section 1 Please use a black pen to fill in this
Claim for Housing Benefit and Application for Council Tax Support (Help with your rent and Council Tax) Please complete this form in BLACK ink, and place a TICK (a) in the relevant boxes. Please read the
Name: Current address: Post code: CHB1 Home telephone number: Mobile number: Email address: IMPORTANT INFORMATION THE MORAY COUNCIL COUNCIL TAX REDUCTION & HOUSING BENEFIT CLAIM FORM 1st contact Issued
Sedgemoor District Council Application for Rent (Housing Benefit) & Council Tax Benefit Please complete and return this form to: The Benefits Service, Bridgwater House, King Square, Bridgwater, Somerset
Help with your Rent and Council Tax Please tear off pages 1 to 4 for your reference Important information if you or your partner are awarded Universal Credit from the DWP If you or your partner are awarded
For Office Use Only Ben Ref o: Date of Issue: Reason for Issue: Receipt Stamp HOUSIG BEEFIT, COUCIL TAX BEEFIT AD SECOD ADULT REBATE CLAIM FORM ou should complete and return this form as soon as you can.
www.islington.gov.uk Application form for Housing Benefit (including Local Housing Allowance) and/or Council Tax Support (including Second Adult Discount) If you are on a low income, you could get Housing
South Norfolk Council Swan Lane Long Stratton Norwich Norfolk NR15 2XE Housing Benefit and Council Tax Support Application Part 1 About you and your household This is my claim for: Housing Benefit Council
For Office Use Only Date of issue First point of contact Ref Name and address of applicant (including room or flat number) Name: Address: : Application form for Housing Benefit and/or Council Tax Reduction
Date requested Date issued Ratepayer ID Occupancy ID THIS BOX FOR OFFICIAL USE (Find these details on your rate bill) START THE FORM HERE Claim number r name and address FOR OFFICIAL USE HELP WITH RATES
APPLICATION FOR HOUSING BENEFIT, LOCAL HOUSING ALLOWANCE AND COUNCIL TAX REDUCTION Please note this form is also available in Welsh Housing Benefits Ty Elwyn, Llanelli, SA15 3AP. Tel: (01554) 742100 E-mail:
Housing benefit & council tax support New claim www.portsmouth.gov.uk You must complete and return the form immediately, even if not all the evidence is available. Delay may affect the start date of your
Carer s Allowance Claim form l Use this form to claim Carer s Allowance. l Please read the tes that came with the claim pack before you fill in the form. l The form must be filled in by you, the carer,
For Official use only Date Requested... Date Issued... Originating Office... Claim Reference... Name... Address......... Postcode... Housing benefit and council tax reduction application form Please use
A claim form for: Housing Benefit An application for: Council Tax Reduction Scheme Second Adult Rebate Name: Address you are claiming or applying for: Address and postcode: Please read the guidance notes
If you need any help please ring: ( 0845 070 1066 Charged at local rate Name and address Date Issued Ref Housing Benefit & Council Tax Support - NEW CLAIM and Free School Meals Use this form to claim Housing
Name: Address: Postcode: Revenues and Benefits Council Offices South Street Rochford Essex SS4 1BW Phone: 01702 318197 or 01702 318198 Email: firstname.lastname@example.org Housing Benefit and Council
Sheffield Benefits Service April 2013 Housing Benefit & Council Tax Support for people of working age Housing Benefit and Council Tax Support Housing Benefit is a national welfare benefit, administered
Phone: 01656 643643 Minicom: 01656 643671 E-mail: email@example.com Bridgend County Borough Council PO Box 107 Bridgend CF31 1WB Name: Address: Reference number: Date issued: Date of first contact:
For our use only.../... Claims Management Claim Form When you have filled in the form, please send it to us at: Solicitors Regulation Authority Claims Management The Cube 199 Wharfside Street Birmingham
Housing Benefit & / or Council Tax Reduction Application Form for Applicants of Working Age PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS Name Address Are you? (Please tick all that apply): An Owner Occupier
Housing Benefit & Council Tax Reduction Change of Income Form HBCOCFRM Part 1 - Personal Details First name Surname Full Postal address uoy rentrapruoy Tel.. Email address edoctsop edoctsop National Insurance
Change of Address Form Help with your Rent and Council Tax Please do not write in this box. It is for office use only. Office receipt date stamp of issue: Please read all of the notes shown on this page
Housing Benefit and Council Tax Reduction Claim Form Please detach this information sheet and keep for future reference. tes for filling in the Housing Benefit and Council Tax Reduction claim form About
Housing Benefit, Council Tax Reduction and Free School Meals tification of Change of Address Mae r ffurflen hon ar gael yn Gymraeg o Ganolfan Ddinesig This form is also available in large print from the
Revenues & Benefits Service Community Contact Centre Town Hall, Queens Square Hastings TN34 1TL Tel: 01424 451080 Fax: 01424 451541 firstname.lastname@example.org www.hastings.gov.uk FOR OFFICE USE ONLY Date
A claim form for Housing Benefit and Council Tax Support If you need help or more information, please contact Hounslow Revenue Services either by phone on 020 8583 4242 or or in in person at at any any
Finance and Customer Services Revenues and Benefits CLAIM FOR HOUSING BENEFIT COUNCIL TAX REDUCTION Name Address Postcode Home Number Mobile Number Email Address Issuing Office Date Issued Reason Issued
APPLICATION FOR FINANCIAL ASSISTANCE ALTERNATIVELY APPLY ONLINE VIA THE FUND S WEBSITE WWW.NPOWERENERGYFUND.COM BEFORE COMPLETING THE APPLICATION FORM, PLEASE CAREFULLY READ THE NOTES BELOW. When you have
Claim form for Housing Benefit and application for Council Tax Reduction Name and address of the person claiming or applying: Reference number: For office use only Issue date: Date received: Revenues and
HOUSING BENEFIT AND COUNCIL TAX BENEFIT Help with rent and Council Tax for pensioners Revised April 2010 Help with paying your rent and Council Tax if you are a pensioner We have written this leaflet for
ISSUE CLAIM REF. DATE: TYPE: NO: APPLICATION FORM FOR HOUSING BENEFIT AND/OR COUNCIL TAX SUPPORT Before completing this application please ensure that you read the notes. In addition to this the evidence
Choice Homes housing application form Attach passportsize photograph (you) Attach passportsize photograph (your partner, if this applies) Important information - please read this before you fill in your
HOUSING BENEFIT AND COUNCIL TAX SUPPORT 2015-16 www.havering.gov.uk What are Council Tax Support and Housing Benefit? Council Tax Support helps people pay their Council Tax. The Government decided to replace
HB1- HOUSING BENEFIT CLAIM FORM FOR NEW CLAIMS Do not use this form if you currently receive Housing Benefit and are moving home ask for a Change of Address form instead. Complete all the sections that
HC BEN 1 Application form for Housing Benefit, Council Tax Reduction and Second Adult Rebate If you and/or your partner have capital of more than 16,000 and you or your partner are in receipt of Job Seeker
APPLICATION FORM Application for Housing Registration The purpose of this application form is to register your need for housing. Registration does not guarantee that you will be made an offer of accommodation.
Malvern Hills District Council 9973 Application for Council Tax Support or Housing Benefit (or both) Name For our use only Date you first contacted us Address Address and and Date you first contacted us
Fees and Remissions Although this form is not part of the ET1 it must be returned with the claim form if you are making your claim by post. This will assist our staff in confirming that the correct fee
Getting your tax credits claim form right Use these Notes to help you TC600 Notes for use from 6 April 2015 Claiming as a couple You must claim as a couple if you are married, living with someone as if
Glasgow City Council Housing Benefit and Council Tax Reduction Application Information Section 1 Personal Details To help us process your application and allow us to contact you if we need more information,
Housing Benefit and Council Tax Support Please return this form immediately so that you do not lose benefit even if you do not have all the supporting documentation. Housing Benefit reference: (if known)
For office use only App. type Initial Surname Registration. RICHMOND HOUSING REGISTER CHANGE OF CIRCUMSTANCES FORM GUINNESS TRUST RICHMOND HOUSING REGISTER CHANGE OF CIRCUMSTANCE FORM Please answer all
Housing Benefit, Council Tax Rebate and Second Adult Rebate Claim Form Date Issued 1st Contact Claim Number If you have any special needs that prevent you getting to our offices or you need help in filling
How to Guide (Getting your Deferment Application Form right) Use these notes to help you complete your student loan Deferment Application Form If you need any help, please go to www.erudiostudentloans.co.uk
How we work out child maintenance A step-by-step guide About this leaflet This leaflet explains how the Child Maintenance Service works out child maintenance. It tells you the information we use and the
Application Form PLEASE READ THIS FORM IN FULL BEFORE COMPLETING IT Please complete all sections of this form when applying for the grant. Please send your completed application form and relevant documentation
The CILEx Compensation Fund Claims Application Form Please complete this form to make a claim for a loss you have incurred. When you have filled in the form, please send it to us at: The CILEx Compensation
Introduction XX Information on transferring payments to the UK 37 National Insurance Number 46 Jobseekers allowance 52 Crisis loans 60 Income support 65 Working Tax Credit 73 Statutory Sick Pay 78 Incapacity
Ochil View Housing Association Ochil House Marshill Alloa FK101AB 01259 722899 email@example.com Registration Form National Housing Trust properties at The Glen Coalsnaughton Mid-market
HOUSING BENEFIT AND COUNCIL TAX BENEFIT Help with rent and Council Tax for people of working age Help with rent and Council Tax for people of working age We have written this leaflet for people of working