Housing Benefit claim form

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1 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, and of this form. Please send any proof with the claim form. Use 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. The application form states what supporting evidence is required to allow us to process a claim. These documents must be original, photocopies will not be accepted. Receipts will be given for claims accepted at your local office, if requested. 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 rest to us later.

2 Contact details: Contact details: Please return the form either by: Post to: Benefits Section Allerdale Borough Council Allerdale House Workington CA14 3YJ Please return the form either by: Post to: Benefits Section Copeland Borough Council The Copeland Centre Catherine Street Whitehaven CA28 7SJ Please return the form either by: Post to: Benefits Section Carlisle City Council Civic Centre Rickergate Carlisle CA3 8QG Or in person at the one of the following offices: Workington Allerdale House Workington CA14 3YJ Cockermouth Customer Services Centre Fairfield Car Park Cockermouth CA13 9RT Keswick Customer Service Centre Main Street Keswick CA12 5JP Maryport Town Hall, Senhouse Street Town Hall, Senhouse Street Maryport CA15 6BH Wigton Local Links, Community Office Market Hall Church Street Wigton CA7 9AA Our Opening times are Monday to Thursday 9.00am 5.00pm; Friday 9.00am 4.30pm. Phone: Fax: Opening times for telephone enquiries Monday, to Tuesday Thursday & Thursday 9.00am 9.00am 5.00pm 5.00pm Wednesday Friday 9.00am 1.00pm 4.30pm 5.00pm Friday 9.00am 4.30pm. Or in person at the one of the following offices: Customer Contact Centre at the Copeland Centre Monday, Tuesday and Thursday 8.45am 5.15pm; Wednesday 10.00am 5.15pm; Friday 8.45am 4.30pm Millom Council Office St George s Road Millom LA18 4DD Monday, Tuesday, Thursday and Friday 9.00am 4.00pm 3.00pm, Wednesday closed for lunch 9.00am 12:15pm 12.00pm - 12:45pm. Cleator Moor Council Office Local Links Market Square Cleator Moor Cumbria CA25 5AP Monday, Tuesday, Thursday and Friday 9.00am 5.00pm Wednesday and Saturday 9.00am pm Phone: Fax: Opening times for telephone enquiries: Monday, and Tuesday Tuesday and 9.00am Thursday 8.45am 5.00pm 5.15pm Wednesday 10.00am 5.15pm Friday 8.45am 4.30pm. Or in person at Carlisle City Council s Customer Contact Centre in the Civic Centre, Ground Floor: We are open between 9.00am and 5.00pm Monday to Thursday and 4.00pm Fridays. If you cannot leave your house we can arrange for a member of staff to visit you. Phone: Fax: Opening times for telephone enquiries: Monday to Thursday 9.00am 5.00pm Friday 9.00am 4.00pm.

3 A claim form for Housing Benefit and / or an application for the Local Council Tax Reduction Scheme Contact details: For office use only Date form was requested Date form was issued Local authority office date stamp If you are just claiming Second Adult Reduction, only fill in Parts 1, 3, 16, 17, and of this form. Part 1 About you and your partner Do you have a partner who normally lives with you? We use partner to mean a person you are married to or a person you live with as if you are married to them, or a civil partner or a person you live with as if you are civil partners. Are you (please tick every box that applies to you): a hostel tenant? an owner-occupier? a joint owner occupier? a private tenant? a housing association or living in Board & Lodgings? social landlord tenant? If you have a partner, you must answer all the questions about them, as well as yourself. You Your partner Surname or family name Initials Other names This claim form should be returned along with all supporting evidence by Any other names you have used Title (Mr, Mrs, Ms, other) Address, including room number if you have one Do not tell us your partner s address if it is the same as yours. Reference Number What date did you move to this address? Your daytime phone number Code Number Code Number What is this number? Please tick. Date of birth Home Work Mobile Textphone Home Work Mobile Textphone

4 page 2 Contact Part 1 details: About you and your partner continued National Insurance (NI) number You can find this on payslips, letters about your benefit or letters from the tax office. We cannot normally decide your claim if we do not have your NI number. We need to see proof of this. You Letters Numbers Letter If you do not have a NI number, or cannot find it, tick this box. Your partner Letters Numbers Letter If your partner does not have a NI number, or cannot find it, tick this box. Your address. Have you or or your partner ever ever received received Housing Housing Benefit, Council Benefit, Tax Council Benefit Tax or Benefit, a Local Council Universal Tax Credit Reduction? or a Local Council Tax Reduction? When did you last get Housing Benefit, Council Tax Benefit, or Universal a Local Council Credit or Tax a Local Reduction? Council Tax Reduction? Please tell us about it below. Please tell us about it below. Which council did you claim from? What name did you use for the claim? What address did you claim for? If you have moved from this address, have you told the council you claimed from? If you or your partner have moved home in the last 12 months, tell us your last address if it is different from the above. Tell us whether you were the homeowner, a private tenant, a council tenant or a lodger at this address. We need to see proof of your and your partner s identity and NI number. See the checklist at Part 20 18

5 Contact Part 1 details: About you and your partner continued page 3 You Your partner 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 two years? We may write to you about this. We may write to you about this. What is your nationality? If your nationality is not British, on what date did you last enter and apply to stay in the UK? The UK is England, rthern Ireland, Scotland and Wales. Are you or your partner in hospital at the moment? Please tell us about it below. Please tell us about it below. When did you go in? When will you come out, if you know? Do you or your partner get Disability Living Allowance / Personal Independence Payment (PIP)? Living / Care Mobility 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 been told that you are entitled to Carer s Allowance, even if you do not receive it, because you are getting another benefit instead?

6 page 4 Contact Part 1 details: About you and your partner continued page 4 You Your partner Do you or your partner have pay towards a Part carer other 1 About you and your partner continued the than upkeep a member of a of student? your household who stays How much many nights do you per pay week? and how often? How much many nights do you per pay week? and how often? overnight in your property? page 4 Part 1 About You you and your partner continued every Your partner every page 4 Part 1 About you and your partner continued Do Are you or your partner pay a student? towards Do they stay in separate bedroom? the By student upkeep we of mean a student? anyone who is attending a You Your partner You How much do you pay and how often? How Tell us much if this do is full you or pay part and time. how often? course of study at an educational establishment, Tell us if this is full or part time. Your partner Do including you or student your partner nurses. pay towards the upkeep of a student? every every Do you or your partner pay towards Full How time much do you Part pay and time how often? How Full time much do you Part pay and time how often? Are the you upkeep you in or Further your of a partner student? or Higher a education? student? How much do you pay and how often? How much do you pay and how often? By student we mean anyone who is attending a Further Higher every Further Higher every Tell us if this is full or part time. course of study at an educational establishment, Tell us if this is full or part time. every every including Are you or your partner a student? Which college student do nurses. you attend? By Are student you or we your mean partner anyone a student? who is attending a Full time Part time Tell us if this is full or part time. Tell Full us time if this is full or Part part time time. Are course What By student you is of the in study Further we full mean title at an or of anyone Higher educational your course? education? who establishment, attending a including student nurses. Tell us if this is full or part time. Tell us if this is full or part time. course of study at an educational establishment, Further Higher Further Higher including student nurses. Full time Part time Full time Part time Do Are you you in recieve Further a or grant Higher or loan? education? Which college do you attend? Full time Part time Full time Part time Are you in Further or Higher education? Further Higher We need to see proof of this Further Higher We need to see proof of this What is the full title of your course? Further Higher Further Higher Which college do you attend? Are you in legal custody (this includes being Do What released Which you college is the recieve on full temporary do you attend? title a grant of your or licence course? loan? or an end of custody licence) What is the full title of your course? We need to see proof of this We need to see proof of this Do Where you are recieve you currently a grant being or loan? held? Do you recieve a grant or loan? We need to see proof of this We need When Are you did in you legal enter custody legal custody? (this includes being to see proof of this / / / / released on temporary licence or an end of We need to see proof of this We need to see proof of this What custody is your licence) earliest release date? Are you in legal custody (this includes being Where are you currently being held? Are released you in on legal temporary custody licence (this includes or an end being of released custody licence) When did on you temporary enter legal licence custody? or an end of custody Where are licence) you currently being held? What Where is are your you earliest currently release being date? held? When did you enter legal custody? When did you enter legal custody? What is your earliest release date? What is your earliest release date?

7 Contact Part 2 details: About children page 5 We need to know about any children in your household who are: under 16, aged 16 or 17 and registered for work or youth training, or aged 16, 17, 18 or 19 and in education doing a course not higher than GCE A-level, SCE Higher level or GNVQ (advanced). Are there any children in your household as described above? Go to Part 3. If there are more than four children, use a separate sheet of paper to tell us all the information we ask for on this page and send it with the form. If you are sending a separate sheet of paper, tick this box. First child Second child Third child Fourth child Surname or family name Other names 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.

8 page 6 Part 2 About children continued page page 6 page 6 Does the child have any savings? Does the child have any Does savings? the child have any savings? Does the child have any savings? Is the child registered blind? Is the child registered blind? Is the child registered blind? Is the child registered blind? Does the child get Disability Living Allowance? Does the child get Disability Living Does the Allowance? child get Disability Care Living Does page the Allowance? 6 child get Disability Living Allowance? Care Mobility Care Mobility Care Does the child have any Mobility savings? Do you or your partner pay Mobility any childminding costs for this child to a registered childminder, a Do you or your partner pay any Do nursery childminding you or your an after-school costs partner for this pay club? child any childminding Do to a you registered or your costs childminder, partner for this pay child a any to childminding Tell Is the nursery a us registered the or name unable an registered costs after-school childminder, and to for registration share blind? this a club? child a nursery to number bedroom a registered of or due the an to minder. after-school childminder, their disability? club? a nursery or an after-school club? Tell us the name and registration Tell number us the of name the minder. and registration Does Tell number us the of child name the minder. get and Disability registration Living number How much Allowance? of the do you minder. pay a week? How much do you pay a week? Care How much do you pay a week? How Are these much term do you time pay only a week? costs? Mobility Are these term time only costs? Are these term time only costs? Are these term time only costs? Do you or your partner pay any childminding costs for this child to a registered childminder, a nursery or an after-school club? Part About children continued Contact Part 2 details: About children continued Part 2 About children continued First child Second child Third child Fourth child First child Second child Third child Fourth child First child How much are Second How child much are Third How childmuch are Fourth How child much are First child their savings? Second their child savings? Third their child savings? Fourth their child savings? How much are How much are How much are How much are their How savings? much are their How savings? much are their How savings? much are their How savings? much are How their savings? much are How their savings? much are How their savings? much are their How savings? much are their savings? their savings? their savings? their savings? How much? First child Second child Third child Fourth child How much are How much are How much are How much are their savings? Please tell us their savings? Please tell us their savings? Please tell us their savings? Please tell us about it below. about it below. about it below. about it below. Please tell us Please tell us Please tell us Please tell us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please about it tell below. us Please provide about it below. Please provide about it below. Please provide about it below. Please provide about it below. further details. further details. further details. further details. Part 2 About children continued a week a week a week a week We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. a week a week a week a week a week a week a week a week We need to see proof of a this. week We need to see proof of a this. week We need to see proof of a this. week We need to see proof of a this. week We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. We need to see proof of this. Please tell us Please tell us Please tell us Please tell us about it below. about it below. about it below. about it below.

9 Contact Part 3 details: About other people who live with you page 7 w tell us about all the people who usually live with you and your partner. Do not tell us about people who just share a hall, bathroom or toilet with you. If you want to tell us about more than three people, use a separate sheet of paper. If you are sending a separate sheet of paper, tick this box. Do any adults usually live with you and your partner? By adults we mean people over 16 who nobody gets Child Benefit for. Go to Part 4. Fill in this section. First Person Second Person Third Person Surname or family name Other names Date of Birth Their relationship to you or your partner Some examples are aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint owner, subtenant, lodger, boarder or friend. Letters Numbers Letter Letters Numbers Letter Letters Numbers Letter Their National Insurance number Do they get Income Support, income-based Jobseeker s Allowance, Pension Credit (Guarantee Credit) or income related Employment and Support Allowance? Do they get Disability Living Allowance, Attendance Allowance or Personal Independence Payment (PIP)? a week a week a week Are they registered blind?

10 page 8 Contact Part 3 details: About other people who live with you continued First Person Second Person Third Person 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? Do they pay rent or money for board and lodgings to you or your partner? a week a week a week Does this include money for food? Does this include money for heating? Are they severely mentally impaired? Are they in legal custody at the moment? When are they expected to be released? When are they expected to be released? When are they expected to be released? What is the name of the establishment where they are currently detained? Are they in hospital at the moment? Tell us about it below. Tell us about it below. Tell us about it below. When did they go in? When are they due to come out (if you know)?

11 Contact Part 3 details: About other people who live with you continued page 9 First Person Second Person Third Person Do they normally work for 16 hours or more a week? Tell us their earnings before any deductions. Tell us their earnings before any deductions. Tell us their earnings before any deductions. per per per We need to see proof of their earnings. We need to see proof of their earnings. We need to see proof of their earnings. Do they have any other income at all? Make sure you tell us about all other income they have. This includes any social security benefits or allowances and interest from savings and investments. Tell us about it below. Tell us about it below. Tell us about it below. 1 Name of the first other income. How much is it before deductions? per per per 2 Name of the second other income. How much is it before deductions? per per per 3 Name of the third other income. How much is it before deductions? per per per We need to see proof of their income? We need to see proof of their income? We need to see proof of their income? Are any of the people who normally live with you married to each other, civil partners, or living together as if they were married or civil partners? We call these people partners. Tell us their names below. is the partner of is the partner of

12 page 10 page 10 page 10 Contact Part 4 About details: Income Support, page 10 income-based Part Jobseeker s 4 About Jobseeker s Allowance, Income Allowance, Support, Pension Credit income-based Pension Jobsee Part Credit (Guarantee 4 (Guarantee About Credit) Income and Credit) page income-related Support, 10 and income-related income-based Employment, Part Credit 4 (Guarantee About Employment Jobseeker s Support Income Credit) Allowance, and Support, Support and income-related Universal income-based Pension Allowance Credit Emplo Jobsee Part Credit 4 (Guarantee About Income Credit) Support, and income-related income-based Credit (Guarantee Employment Jobseeker s Credit) Allowance, and Support and income-related Pension Allowance Emplo Are you or your partner getting or waiting Go to to Part hear 5. about a claim for Income Go to Part 5. Credit (Guarantee Credit) Support, income-based and income-related Jobseeker s Allowance, Employment Pension Credit (Guarantee and Support Credit) Allowance Are you or your partner getting or waiting to hear about a claim for Income Are Support, you or income-based your partner Jobseeker s getting or waiting Allowance, to hear Pension about Credit a claim Are (Guarantee for you Income or your Credit) partner getting Go to Part 5. Support, income-based Jobseeker s and Allowance, Support Allowance? or waiting Answer to both hear the about questions a claim in this for part Income Pension Credit (Guarantee Credit) and then go to Part 5. Go to Part 5. income-related Employment, Support or Universal or Support, Credit? income-related income-based Employment Jobseeker s and Allowance, Support Allowance? Answer both the Pension Credit (Guarantee Credit) Are or income-related you or your partner Employment getting and or waiting Support to Allowance? hear about a claim or income-related for Income Employment and Support Go Answer to Part Allowance? both 5. the questions in this part and then go to Part 5. Answer both the Support, income-based Jobseeker s Allowance, Pension You Credit (Guarantee Credit) Your Partner Your or income-related Employment and Support Allowance? Answer both the questions in this part and then go to Part 5. You Your Partner Income Support Which benefit are you or your partner Your Which benefit are you or your partner Income Support Income Which getting benefit or waiting are you to hear or your about? partner Income-based You Support Jobseeker s Which getting benefit or Allowance waiting are you to hear or your about? partner Income-based Your Support Partner Jobseeker s Allowance Incomegetting or waiting to hear about? Income-based Pension Credit Jobseeker s (Guarantee getting or Allowance Credit) waiting to hear about? Income-based Pension Credit Jobseeker s (Guarantee Allowance Credit) Income- Pension Which benefit are you or your partner Income Support Income Support getting or waiting to hear about? Universal Income-related Pension Credit (Guarantee Employment Credit) Income-based Jobseeker s Allowance Income-based Universal Income-related Pension Credit (Guarantee Employment Credit) Pension Income- Jobseeker s Allowance Income-related and Support Allowance Employment Income-related and Support Allowance Employment Incomeand Sup Are you or your partner actually Income-related Employment Are you or your partner actually Income-related Employment Are and Sup Pension Credit (Guarantee Credit) Pension Credit (Guarantee Credit) and Support Allowance and Support Allowance getting you Income or your Support, partner actually income-based and Support Allowance and Support Allowance When did Are getting you start you Income getting or your Support, it? partner actually income-based they getting Jobseeker s Income Allowance, Support, Pension income-based Credit When did you start getting it? getting Jobseeker s Income Allowance, Support, Pension income-based Credit Are (Guarantee When did you start getting it? they Jobseeker s you or your Credit) Allowance, partner or income-related Pension actually Credit When did you start getting it? // Jobseeker s (Guarantee Credit) Allowance, or income-related Pension Credit getting Employment (Guarantee Income Credit) and Support, income-related income-based Allowance Employment (Guarantee Credit) and Support or income-related Allowance When did you start getting it? When did they start getting it? Jobseeker s Employment at the moment? Allowance, and Support Pension Allowance Credit Employment at the moment? and Support Allowance (Guarantee at the moment? Credit) or income-related at the moment? Employment, and Support Support Allowance and Are you or your partner still waiting Are you or your partner still waiting Universal at the moment? Credit at the moment? Are to hear you about or your a claim partner for still Income waiting When did Are to hear you you about claim? or your a claim partner for to hear about a claim for / still Income / waiting When did they you claim? Support, income-based Jobseeker s Income to Support, hear about income-based a claim for Jobseeker s Income When did you claim? they Support, Allowance, income-based Pension Credit Jobseeker s (Guarantee When did you claim? Are you or your partner still waiting Support, Allowance, income-based Pension Credit Jobseeker s (Guarantee to Credit) Allowance, hear or about income-related Pension a claim Credit for Income Employment (Guarantee When did Allowance, Credit) or income-related you claim? Pension Credit Employment (Guarantee When did they claim? Support, and Credit) Support or income-based income-related Allowance? Jobseeker s Employment Credit) and Support or income-related Allowance? Employment Allowance, and Support Pension Allowance? Credit (Guarantee We must see proof and Support of your Allowance? benefits, allowances or pension We before must we see can proof decide of your how benefits, much Housing allowances Benefit or pension bef Credit) or income-related Employment, or We Council must see Tax proof Reduction of your you benefits, can get. allowances Read the checklist or pension at or We Part before Council must to we see see Tax can proof what Reduction decide of you your how can you benefits, much use can as get. Housing a allowances proof. Read Benefit the checklist or pension at Part bef and Support Support Allowance Allowance? and Universal or Council Tax Reduction you can get. Read the checklist at or Part Council 18 to see Tax what Reduction you can you use can as get. a proof. Read the checklist at Part Credit? We must see proof of your benefits, allowances or pension before we can decide how much Housing Benefit or Council Tax Reduction you can get. Read the checklist at Part 18 to see what you can use as a proof.

13 Contact Part 5 details: About being self-employed page 11 Are you or your partner self-employed? What kind of work do you do? You Go to Part 6. Answer the questions on this page. You 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 proof of your income. We will write to you about this. Your partner When did the business start? What is the business address? Is the company a limited company? Do you have any business partners? If so, how many Directors does the company have? Tell us their name and address. If so, how many Directors does the company have? 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 and how often? How much and how often? every every Do you pay into a private pension scheme? How much and how often? How much and how often? every every We must see proof of your earnings before we can decide how much Housing Benefit or Council Tax Reduction you can get. Read the checklist at Part to see what you can use as proof. Please request the self-employment proforma from from us if us you if you do not do not have have a full a full set set of of accounts.

14 page 12 Do you or your partner work for an employer? What kind of work do you do? Contact Part 6 details: About working for an employer You Go to Part 7. Answer the questions on this page. If you or your partner work for more than one employer, tell us about all the employers on a separate sheet of paper and send it with this form. If you are sending a separate sheet of paper, tick this box. Your partner What is your employer s name and address? When did you start this job? What is your payroll, employee or staff number? Are you employed for a limited period? When will you finish? When will you finish? page 4 How much do you get paid and how often? How are you paid, for example, in cash, by cheque or straight into a bank or building society account? When was your last pay rise? When will your next pay rise be? How many hours a week do you usually work? Do you or your partner pay towards the upkeep Are you of a getting student? Statutory Sick Pay (SSP), Statutory Paternity Pay (SPP), Adoption Pay or Statutory Maternity Pay (SMP) from your employer at the moment? every page 4 You every Part 1 About you and your partner continued Part 1 About you and your partner continued Do you or your partner pay towards the upkeep of a student? How much do you pay and how often? Which payment? Are you Are or you your getting partner any a student? other sick pay or Are you or your partner a student? By student maternity we mean pay anyone from who your is employer attending a at By student we mean anyone who is attending a the moment? Tell us if this is full or part time. Tell us if this is full or part Te course of study at an educational establishment, course of study at an educational establishment, Tell us if this is full or part time. including Do student you pay nurses. into a private or company including student nurses. pension scheme? How Full much timeand Part time every How Full much timeand Part time every Fu Are you in Further or Higher education? how Are often? you in Further or Higher education? how often? We must see proof of of your your earnings before before we can we decide can decide how Further much how Housing much Housing Higher Benefit or Benefit Council or Tax Council Reduction Tax you Reduction can get. you We Further need can get. to see We 5 weekly need Higher to or see 3 fortnightly 5 weekly or 23 monthly fortnightly Fu or payslips. 2 monthly Read the payslips. checklist Read at Part the 18 checklist to see what Part you 20 can to use see as what proof. you If you can get use tips as or proof. bonuses, tell us about these in Part 16. Which college do you attend? Your partner How much do do you you pay pay and and how often? Which payment? every every Which college do you attend? Your par Ho What is the full title of your course? What is the full title of your course?

15 Contact Part 7 details: About any other work page 13 Do you or your partner do any other work at all? This could be voluntary work or any other work, even if it is not paid work. You Go to Part 8. Answer the questions in this section. Your partner What other work do you do? What is the name and address of the person you do this work for? When did you start this work? How many hours a week do you usually work? Do you get paid? If you only get expenses or tips, still tick and give details. How much do you get paid and how often? Tell us about it below. Tell us about it below. every every We must see proof of your earnings before we can decide how much Housing Benefit or Council Tax Reduction you can get. We need to see 5 weekly or 3 fortnightly or 2 monthly payslips. Read the checklist at Part to see what you can use as proof. About bonuses. Give details of any regular overtime, bonuses, tips or commission. How often are these paid? What period do they cover?

16 page 14 Contact Part 8 details: About benefits, tax credits and state pensions 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 claimed? Read the list of benefit and credits below and tell us about any that you or your partner are getting now or have claimed. Please 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. Go to Part 9. Tell us about the benefits below. Pensions State retirement pension Pension Credit (Savings Credit) Widow s Allowance or Bereavement Allowance You How much do you get? How often is it paid? Your partner How much do you get? How often is it paid? Pensions 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 How much do you get? How often is it paid? How much do you get? How often is it paid? Benefits and allowances Contribution-based Job Seeker s Allowance Child Tax Credit Working Tax Credit Employment Training Allowance Child Benefit How much do you get? How often is it paid? How much do you get? How often is it paid?

17 Contact Part 8 details: About benefits, tax credits and state pensions continued page 15 Part 8 About benefits, tax credits and state pensions continued You Your partner Benefits and allowances continued How much do you get? You How often is it paid? How much do you get? Your partner How often is it paid? Short-term Incapacity Benefit Benefits and allowances continued Long-term Short-term Incapacity Benefit Employment Long-term Incapacity and Support Benefit Allowance How much do you get? How often is it paid? How much do you get? How often is it paid? Employment Attendance Allowance and Support Allowance page 15 Disability Attendance Living Allowance Allowance / Personal Independence Payment (PIP): Disability Living Allowance / Personal Mobility Component Independence Payment (PIP): Living / Care Component Mobility Component Carer s Living Allowance / Care Component Carer s Severe Disablement Allowance Allowance Maternity Severe Disablement Allowance Allowance Fostering Maternity Allowance Universal Fostering Credit Allowance Have you or your partner deferred (put off) receiving a Have pension? you or your partner deferred (put off) receiving a pension? If, which one? If, which one?

18 page 16 Contact Part 9 details: About other money coming in Do you or your partner: have any money coming in that you have not already told us about? expect to have any money coming in? Have you or your partner delayed receiving any other money? This includes occupational pensions, work pensions, and private pensions, pension protection fund payments, maintenance or child support for you, your partner or any of the children you have told us about on this form, money from a trust fund, training allowances, a student grant or loan, and any cash payments. Also tell us about any money you get from people living in your house as boarders, lodgers or subtenants. What is the money for? Other money 1 Go to Part 10. Answer the questions on this page. You do not need to tell us about payments from the Independent Living Fund, the Eileen Trust, the MacFarlane Trust or the Skipton Fund. Other money 2 Other money 3 Who gets it? How much do they get? How often? Every Every Every How is this paid? When did they start getting this income? When is the income likely to go up? Does anyone owe money to you or your partner? What for? Who is it owed to? Are you or your partner expecting to get any money in the next 12 months? For example, a redundancy payment or a payment instead of notice or holiday. What for? Tell us about it below. Tell us about it below. Tell us about it below. Tell us about it below. Tell us about it below. Tell us about it below. We must see proof of any money coming in before we can decide how much Housing Benefit or Council Tax Reduction you can get. Read the checklist at Part to see what you can use as proof.

19 Contact Part 10 details: About bank, building society or Post Office accounts page 17 Do you or your partner have any bank, building society or Post Office accounts? Go to Part 11. Tell us about your accounts, even empty or overdrawn ones or accounts you do not use very often. If there are more than 5 accounts, tell us about the others on a separate sheet of paper and send it with this form. If you are a sending a separate sheet of paper, tick this box. Account 1 Account 2 Account 3 Account 4 Account 5 Account 6 Account 7 Account 8 Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Name of bank or building society or Post Office Whose name is the account in? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account? Account number How much is in the account?

20 page 18 Contact Part 11 details: About capital, savings, shares and investments Do you or your partner have any capital, savings or investments in the UK or abroad? This includes Cash, Premium Bonds, National Savings Certificates, and stocks and shares. Do you or your partner have any premium bonds? Do you or your partner have any National Savings Certificates? Value Go to Part 12. Answer all the questions in this part. We must see evidence of all the capital, savings and investments. Please enter details below. Issue number Value How many? Issue number Value How many? Issue number Value How many? Do you or your partner have any stocks, shares, bonds or unit trusts? Please enter details below. Company name Company name Company name How many? How many? How many? Value? Value? Value? Do you or your partner have any other capital, saving or investments? For example, cash, TESSAs, ISA, TOISAs, compensation, or any other money you have not told us about on this form. Please enter details below.

21 Contact Part 11 details: About capital, savings, shares and investments continued page 19 Do you or your partner or any children you are claiming for, own or partly own any property, land or timeshare, other than the home you live in, either in the UK or abroad? Tick even if you have a mortgage or loan due for the property, land or timeshare. What is this address? How much is it worth? If you have a mortgage or loan for this, how much is left to repay? Is it currently for sale? If, how long has it been for sale? What agency is handling the sale? Do any of your savings or investments include: money from the sale of a house, or money from a charity? We will write to you about it. Have you or your partner received: a Far Eastern Prisoner of War Compensation payment, or a compensation payment made to victims of atrocities that happened during the Second World War? We need to know this to make sure we do not count it as part of your savings. Have you or your partner received a payment from the vcjd (Creutzfeldt- Jakob Disease) Trust? What payment did you receive? A Far Eastern Prisoner of War Compensation payment A compensation payment made to victims of atrocities that happened during the Second World War Please provide details. You You You partner You partner We must see proof of any capital, savings or investments before we can decide how much benefit you can get. Read the checklist at Part to see what you can use as proof.

22 page 20 Contact Part 12 details: About where you live Do you own your home or have a mortgage? Answer all the questions below. Go to Part 16. What sort of building do you live in? Tick one box only. Detached house Semi-detached bungalow Hostel Other - give details Semi-detached house Terraced house Flat in a house Flat in a block Caravan, mobile home or houseboat Board and lodgings Maisonette Flat over a shop Hotel Detached bungalow Bedsit or rooms or a studio flat Care home Does your home have any of these? Tick the boxes that apply. central heating a garden a garage a parking space Who is responsible for decorating your home? How many floors are there? Do you and your household occupy only part of the building you have ticked? As you look at the building from the street, where in the building do you live? To the left At the front To the right In the middle At the back Which floors do you live on? For example, ground floor, first floor. How many rooms are there in the building? Living rooms In the whole building Just for you and your household That you share with other people Bedsitting rooms Bedrooms Bathrooms or shower rooms Toilets Kitchens Other rooms

23 Contact Part 13 details: About rent Do you or your partner pay rent for your home? Go to Part 16. Tick If you have if you would claimed pay rent Universal but you already Credit get go to Part 16. Part 13 About rentanswer the next question. Housing Benefit. What Do you is or your your landlord s partner full pay name rent for and your business home? Go to Part 16. address? Tick if you would pay rent but you already get Answer the next question. By Housing landlord Benefit. we mean the person or organisation who What owns is your the landlord s property you full live name in. and business address? By landlord we mean the person or organisation who If your owns landlord the property has an you agent, live in. tell us their full name and address. By agent we mean the person or organisation you If actually your landlord pay your rent has to. an agent, tell us their full name and address. By agent we mean the person or organisation you actually pay your rent to. Is your landlord or agent, or your landlord s or the agent s partner: your former partner; your partner s former partner; What is the relationship? Is your related landlord to you or or agent, your partner; or your landlord s or the agent s partner: related your former to your partner; partner s children? Related your includes partner s related former through partner; marriage or civil partnership, is my landlord s What is the relationship? even related if it has to ended. you or For your example, partner; or agent s ex-wife, related ex-husband, to your partner s ex-civil partner, children? aunt, brother, daughter, father, Related grandson, includes related grandmother, through son-in-law marriage or or civil stepdaughter. partnership, is my landlord s even if it has ended. For example, or agent s ex-wife, When did ex-husband, you or your ex-civil partner partner, start aunt, renting brother, your daughter, home? father, grandson, grandmother, son-in-law or stepdaughter. When did you move to this address? If you have not moved in yet, tell us when you expect to move in, When did you or your partner start renting your home? then tell us when you have actually moved in. What When sort did you of tenancy move to do this you address? have? For If you example, have not shorthold, moved in assured, yet, tell tied us when rent or you something expect to like move this. in, then tell us when you have actually moved in. How long is the tenancy for? What sort of tenancy do you have? For example, shorthold, assured, tied rent or something like this. What is the property let as? Furnished Partly furnished Hardly any furniture Unfurnished How Tick the long box is that the applies. tenancy for? How much rent do you or your partner pay and how often? For What example, is the every property week, let every as? fortnight, every four weeks or calendar monthly. Furnished every Partly furnished Hardly any furniture Unfurnished Tick the box that applies. How much rent do you or your partner pay and how often? For example, every week, every fortnight, every four weeks or calendar monthly. every page 21 page 21

24 What sort of tenancy do you have? For example, shorthold, assured, tied rent or something like this. How long is the tenancy for? page 22 Contact Part 13 details: About rent continued What is the property let as? Tick the box that applies. Does anyone else share the rent with you and your partner? How much rent do you or your partner pay and how often? For example, every week, every fortnight, every four weeks or calendar monthly. page 22 Tell us their names and their relationship to you and your partner. Part 13 About rent continued Furnished Partly furnished Hardly any furniture Unfurnished Tell us the every details below. 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 they pay and how often? For example, every week, every fortnight, every four weeks or calendar monthly. Has your rent changed in the last 12 months? How much of the rent do they pay and how often? For When example, is the every next week, rent increase every fortnight, due? every four weeks or calendar monthly. Has your rent changed been registered in the last a 12 fair months? rent by a rent officer? When is the next rent increase due? Do you have any weeks when you do not have to pay rent? Has your rent been registered as a fair rent by a rent officer? Are you behind with your rent? Do you have any weeks when you do not have to pay rent? Who has to pay the Council Tax bill for your home? Are you behind with your rent? Tick the box that applies. Who has to pay the Council Tax bill for your home? Tick What the is box the that Council applies. Tax reference number? every Send us proof of the date it changed and how much it changed. every Send us proof of the date it changed and how much it changed. Please send us the notice of registration form R05. How many in a year? Please send us the notice of registration form R05. You or your partner Your landlord Someone else You or your partner Your landlord Someone else Tell us the details below. By how many weeks? How many in a year? By Tell how us who many it is. weeks? Tell us who it is. What is the Council Tax reference number? We must see proof of your rent and tenancy before we can decide how much Housing Benefit you can get. Read the checklist at Part to see what you can use as proof.

25 Contact Part 13 details: About rent continued page 23 Does your rent include money for the following? Tick the boxes that apply. Meals every For which meals? Please tick. Breakfast Lunch Evening meal Water authority charges Heating Lighting Hot water Electricity Fuel for cooking Laundry Cleaning rooms or windows Gardening Garage or parking space every every every every every every every every every every Do you have to rent the garage as part of your tenancy agreement? Personal care and support Do you pay any service charges separate from your rent, for example, for cleaning or lighting in shared areas, an alarm system, a warden, general counselling or support, meals or lift maintenance? every every What for? Are you living away from home at the moment? Why are you not living at home? Tell us about it below.

26 page 24 Contact Part 13 details: About rent continued When did you last live at home? When do you expect to go back home? What is the address of where you are living at the moment? Have you sublet your home? Who lives there now? We must see proof of your rent and tenancy before we can decide how much Housing Benefit you can get. Read the checklist at Part to see what you can use as proof.

27 Contact Part 14 details: Payment of Benefit page 25 If you are in receipt of Local Housing Allowance, payment will be made directly into your bank/building society account. Payment direct into an account We recommend that you get your money in this way because: The account can be: it is safe and secure; it is convenient - you decide when and how much you want to withdraw; using an account may help you to save; from some accounts you could have regular bills paid (this could save you money but you will need to make sure that there is enough money in your account to pay the bills - if not, you may be charged a fee); and you can get your money from many different places. in your name; in the name of your partner (we use partner to mean a person you are married to or a person you live with as if you are married to them); in both the names of yourself and your partner; or in both the names of yourself and the person acting on your behalf. If we cannot pay you directly into an account, we will pay you by cheque. If your landlord is a Registered Social Landlord or you are an exempt tenant from Local Housing Allowance, you can choose where to have your Housing Benefit paid. For Carlisle City Council claimants and Copeland Borough Council claimants we can arrange to pay your money (please tick as appropriate): direct into your bank or building society account (Please input your bank details below) If you are making a claim with Allerdale Borough Council and do not have a bank account, please contact the Allerdale Benefits Office by cheque (where you do not have a bank account or are unable to open one) or your Local Customer Service Centre for further information. direct to your landlord. (Please input your landlords bank details below) Please give your/your landlords account details below. Name of the bank or building society Address of the bank or building society (including the postcode) Whose name is the account in? Account Number Sort Code

28 page 26 Contact Part 15 details: Payment of Benefit to Landlords If you are not a private tenant and you want us to pay your benefit straight to your landlord, you must sign this declaration. Your declaration Please pay my Housing Benefit straight to my landlord. I understand that I must always tell you about any change in my circumstances. I understand that if I do tell you about any change of circumstances and you pay me too much benefit because of this, I may have to pay back the extra benefit. I understand that I may be prosecuted if I do not tell you about any change of circumstances. Housing Benefit can be paid to your landlord if :- You rent your property from a Housing Association or, You rent your property from a Supported Housing provider or, Your tenancy started before 15 January 1989 or You have not moved house or room since 7 April 2008 and have had an unbroken claim for benefit since then. Signature Please make Housing Benefit payments direct to my landlord (Please tick the box) Your landlord must sign the declaration below if you choose this option. Full name (in CAPITAL LETTERS) Date Your landlord s declaration I agree to accept Housing Benefit payments for the tenant named in this form. I understand that by law: I must tell you straight away if I find out about any change in the tenant s circumstances; you can stop paying benefit to me if I do not tell you about any change of circumstances; I can be prosecuted if I accept Housing Benefit which I know I am not entitled to; and if you pay me too much Housing Benefit for any tenant, I may have to repay it. You can take the amount of overpaid benefit from the benefit I get for any other tenants. This will not affect their rent. Signature Date Full name (in CAPITAL LETTERS)

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