Claim form for Housing Benefit & Council Tax Support

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1 Caim form for Housing Benefit & Counci Tax Support Pease make sure you answer a the questions using back ink ony. Do not use penci, correction fuid or tape. Answer a no or yes questions by putting a 3 in the reevant box. If you need hep with this form pease ring us on Pease read through the notes on the foowing pages before competing the form.! You must return this form to us as soon as possibe, even if you are waiting for proof of your income, rent or any other detais. If you do not you may ose some benefit. Your name and address Name: Address: OFFICE USE ONLY Date issued / / Date received (stamp): : Caim number Are you (pease tick one) a private tenant? a Curo tenant? a housing association or socia andord tenant? iving in a hote or bed & breakfast? an owner occupier?

2 Notes for fiing in the caim form for Housing Benefit and Counci Tax Support About this form About Housing Benefit and Counci Tax Support Loca Housing Aowance Evidence/Proof Fiing in the form If you need hep to fi in the form What to do next Changes you must te us about How we coect and use information About this form We have designed this caim form to be easy to fi in. It may ook rather ong, but there needs to be enough questions to make sure that everyone who caims gets the right amount of benefit. You may not have to fi in a of the form (for exampe, a few questions woud not appy to most pensioners) but you must fi in any part that is reevant to you. Every part starts with a question to hep you decide if you need to fi in that section. About Housing Benefit and Counci Tax Support Housing Benefit can pay a or part of your rent. It may aso give you some extra money towards things you have to pay for, ike chidren s pay areas and ceaning shared areas. It can aso hep with certain support charges if they are incuded with your rent. Counci Tax Support can pay a or part of your Counci Tax. It cannot hep with water charges. Loca Housing Aowance Loca Housing Aowance (LHA) arrangements are a way of working out Housing Benefit for peope who rent from a private andord. The rate used to work out how much benefit you can get is based on the size of your househod and how many bedrooms you need. Evidence/Proof We wi need to see evidence of some of the things you write about on the form. There is a checkist after the decaration to hep you. If you are not sure if we need to see evidence of something, get in touch with us. We wi te you what we need to see. We cannot pay you benefit unti we have seen the evidence we need. Fiing in the form Use back ink on the form. Do not use penci. If you make a mistake, just cross it out and write the correct answer next to it. Do not use correction fuid or tape. Answer Yes or No questions by putting a tick in the reevant box. If you are picking an answer from a ist, tick the appropriate box. If someone ese fis in the form for you, there is a specia space for them to sign as we. If you need hep to fi in the form Pease contact us if you need hep to fi in the form. Our contact detais are shown in part 19. 2

3 What to do next When you have fiied in and signed the form, either post it to us or visit one of our offices with the evidence we need. Our contact detais are shown in part 19. Do not send vauabe items such as bank books or passports in the post. Bring them to us and we wi get the information we need and give them back to you. If you cannot get the evidence we need straight away, do not worry. Send the form to us with the evidence you do have and et us know that you wi be sending some evidence ater. If you do not send the form to us straight away, you might ose money. Changes you must te us about You must te us if: any of your chidren eave schoo or eave home anyone moves into or out of your home, incuding odgers and subtenants your income or income of anyone iving with you, (incuding benefits) changes your capita or savings change you or anyone iving with you becomes a student, starts a youth training scheme, goes into hospita or nursing home, goes to prison, or changes or eaves a job your rent changes you move you or your partner are going to be away from home for more than a month you or anyone iving with you starts work you receive any decision from the Home Office there are any changes to your chidcare costs, or anything you have tod us about changes. This is not a fu ist. If you are not sure, ask us for advice. If you do not te us about these changes, you may ose money you are entited to or you may get too much benefit. You must make sure that you te us about any changes. Don t rey on someone ese to pass the message on. It is an offence not to te us about any changes of circumstances that affect your benefit. We may take court action against you, and if we pay you too much benefit, you wi probaby have to pay it back. How we coect and use information We wi use the information you give in this form, and in any supporting evidence you send, to process your caim for Housing Benefit and Counci Tax Support. We may pass the information to other agencies or organisations such as the Department for Work and Pensions and Her Majesty s Revenue & Customs, as aowed by aw. We may check information you have provided, or information about you that someone ese has provided, with other information we hod. We may aso get information about you from certain third parties, or give information to them to: make sure the information is accurate prevent or detect fraud, and protect pubic funds. These third parties incude government departments, other oca authorities, and private-sector organisations such as banks and organisations that may end you money. They wi not give information about you to anyone ese, or use information about you for other purposes, uness the aw aows this. We are the data controer for the information on this form for the puposes of the Data Protection Act. Information wi normay be hed for six years. If you want to know more about what information we have about you, or the way we use that information, pease ask us. 3

4 Part 1: About you and your partner What date did you move into your current home? / / If you have not moved in yet, when do you expect to move in? / / Do you have a partner who normay ives with you? No Yes A partner is someone (of the same or opposite sex) you ive with as part of a coupe, as if you were married or civi partners. If you are married, in a civi partnership or have a partner, you must put their detais on this form. Last name First names Tite (Mr/Mrs/Miss etc.) Any other names you have used You Your partner Address (incude the room or fat number). Do not te us your partner s address if it is the same as yours. Date of birth / / / / Nationa Insurance number You can find this on paysips or etters from the DWP or the tax office. We cannot normay decide your caim if we do not have your Nationa Insurance number. If you do not have a Nationa Insurance number, or cannot find it, tick this box. If you are waiting to be aocated a Nationa Insurance number, tick this box. If your partner does not have a Nationa Insurance number, or cannot find it, tick this box. If your partner is waiting to be aocated a Nationa Insurance number, tick this box. Gender Mae Femae Mae Femae Your daytime teephone number Emai Preferred method of contact If you have moved home in the ast 12 months, te us your ast address We need to see at east two origina documents as proof of your identity and your partner s identity (if you have one). We wi accept documents such as: a passport: a birth certificate; two recent bank or buiding society statements; a driving icence; a marriage certificate; a gas, eectricity or water bi; a etter from Jobcentre Pus; a credit card or credit card statement; a etter from the Department for Work & Pensions; a etter from HM Revenue & Customs; a etter from your socia worker or doctor; a etter from The Pension Service; or a P45 or P60; a etter from your soicitor. We need to see one origina document as proof of Nationa Insurance number for you and your partner (if you have one). We wi accept documents such as: a Nationa Insurance number card (RD3); paysips or saary sips; a etter from the Department for Work & Pensions; a etter from HM Revenue & Customs; or a P45 or P60; a etter from The Pension Service. 4

5 Part 1: About you and your partner (continued) Have you or your partner caimed You Your partner Housing Benefit or Counci Tax Support before? No Yes No Yes If Yes, when did you caim? What address did you caim for? Have you or your partner come to ive in the UK, Ireand, Ise of Man or Channe Isands in the No Yes No Yes ast five years? If Yes, when? / / / / What nationaity are you and your partner? Are you or your partner an asyum seeker? No Yes No Yes We wi need to see etters from the Home Office Border & Immigration Agency. Are you or your partner in hospita at the moment? No Yes No Yes If Yes, when did you go in? / / / / When do you expect to come out? / / / / Do any of the foowing circumstances appy to you or your partner? You Your partner In ega custody Registered bind Under 22 years od and have been in care 5

6 Part 2: About your chidren who ive with you How many chidren ive with you? If you have none, write none and go to part 3. By chidren we mean young peope under 20 who are sti at schoo. Te us their detais beow. If you have more than six chidren, use a separate sheet of paper and tick this box. Last name First names First chid Second chid Date of birth / / / / Their reationship to you Gender of chid Mae Femae Mae Femae Who gets the Chid Benefit for them? Last name First names Third chid Fourth chid Date of birth / / / / Their reationship to you Gender of chid Mae Femae Mae Femae Who gets the Chid Benefit for them? Last name First names Fifth chid Sixth chid Date of birth / / / / Their reationship to you Gender of chid Mae Femae Mae Femae Who gets the Chid Benefit for them? If any of the chidren are registered bind or getting Disabiity Living Aowance, give their names. If you have chidren, we need to see evidence such as a etter from Chid Benefit, Chid Tax Credits or a birth certificate. You Your partner Do you make payments to a registered chidcare provider to No Yes No Yes ook after a chid aged 15 or under (16 or under if the chid is disabed)? How much? per week per week Pease state the name and Name Name registered number of the chidcare provider Number Number Do you receive chidcare vouchers? No Yes No Yes How much? 6 We need to see evidence of chid care costs, such as invoices or receipts on headed paper.

7 Part 3: About other peope who ive with you Do any aduts normay ive with you and your partner? By aduts we mean peope over 16 who nobody receives Chid Benefit for. You shoud aso incude carers when a bedroom has been aocated for their use. If you are sending a separate sheet of paper, tick this box. Are any of the peope who normay ive with you married to each other, in a civi partnership or iving together as if they are married or in a civi partnership? No No Yes Te us about a the aduts (except your partner) who usuay ive with you. If you need to te us about more than 3 peope, use a separate piece of paper. Yes Te us their names. Now te us about other peope who normay ive with you and your partner. Last name First person Second person Third person First names Date of birth / / / / / / Their reationship to you (For exampe, aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint owner or a friend.) If they are a joint tenant or joint owner, write this in and go to part 4. Do they get Income Support, No No No income-based Jobseeker s Aowance, ESA or Yes Yes Yes Pension Credit? Do they get Disabiity Living No No No Aowance or Attendance Aowance, or are they Yes Yes Yes registered bind? Are they a fu-time student, a No No No student nurse, a care worker, an apprentice or on youth Yes Yes Yes training? 7

8 Part 3: About other peope who ive with you (continued) First person Second person Third person Are they in ega custody No No No at the moment? Yes Yes Yes Expected reease date / / / / / / Are they in hospita at No No No at the moment? Yes Yes Yes When did they go in? / / / / / / When are they expected to come out? / / / / / / Are they working No No No at the moment? Yes Yes Yes How many hours per week? Te us their earnings before deductions for things ike tax and Nationa Insurance. How often are they paid? We need to see proof of their earnings. Do they have any other No No No income at a? Yes Yes Yes Te us their other income before deductions for things ike tax and Nationa Insurance. How often are they paid? We need to see proof of their income. Subtenants First person Second person Third person Are any of the peope who ive No No No with you subtenants or boarders who pay you or your partner rent Yes Yes Yes or money for board and odgings? Amount charged? How often? Do you give them meas? No Yes No Yes No Yes Amount charged? How often? Do you give them heating? No Yes No Yes No Yes Amount charged? How often? Pease provide evidence of these charges. 8

9 Part 4: About pensions, aowances, benefits and tax credits Are you or your partner getting, or No waiting to hear about any pensions, aowances, benefits or tax credits? Yes Pease te us about them beow. Read the ist beow and tick No if you do not receive the income or have not appied for it. Tick Yes if you do receive the income or have appied for it. You Your partner (tick either box) If Yes, give How often if Yes, give How often No Yes the amount. is it paid? the amount. is it paid? Income Support Job Seekers Aowance Empoyment and Support Aowance Pension Credit Widow s Pension War Widow s Pension or Widower s Pension War Disabement Pension Widowed Mother s Aowance Disabiity Living Aowance Care Component Disabiity Living Aowance Mobiity Component Carer s Aowance Maternity Benefit Severe Disabement Aowance Attendance Aowance Incapacity Benefit Industria Injuries Benefit Chid Benefit Chid Tax Credit Working Tax Credit Other (pease specify) We need proof of pensions, aowances, benefits, or tax credits. We can accept etters from The Pension Service, Jobcentre Pus, the Department for Work and Pensions or HM Revenue & Customs. 9

10 Part 5: About being sef-empoyed Are you or your partner sef-empoyed? No Yes If Yes pease answer the questions on this page. You must send us your audited trading accounts for the ast financia year. If you have ony recenty set up the business and do not have a fu year s accounts, you wi need to compete a sef-empoyed form. For ess than three months you wi need to compete an initia sef-empoyed form, for more than three months you wi need to compete a fu sef-empoyed form. These forms can be obtained from our website, or you may wish to contact us by teephone or at one of our offices. You Your partner What kind of work do you do? When did the business start? / / / / What is the address of the business? Do you have any business No No partners? Yes Yes Te us their name and address How many hours do you normay work? Do you get a Business No Yes No Yes Start-up Aowance? How much and how often? every every Do you pay into a private No Yes No Yes pension scheme? How much and how often? every every We must see evidence of your earnings before we can decide how much benefit you can get. Other information regarding sef-empoyment you think may be usefu:- 10

11 Part 6: Your earnings Are you or your partner working (incuding No vountary work), receiving Statutory Sick Pay or Statutory Maternity/Paternity Pay? Yes Pease te us about this beow. You Your partner Who do you work for? What is the company s address? What kind of work do you do? When did you start this job? / / / / How many hours do you normay work each week? hours hours How much are you paid? How often are you paid? (weeky, fortnighty, four-weeky, monthy) How is your wage paid? (by cheque, cash, into your bank account) When is your next pay rise due? / / / / Do you work reguar overtime or get reguar bonuses, tips No Yes No Yes or commission? How much do you get? each each If this job is for a fixed period, pease te us the date it wi end? / / / / Are you getting Statutory Sick Pay (SSP)? No Yes No Yes Are you getting Statutory Paternity Pay (SPP)? No Yes No Yes Are you getting Adoption Pay? No Yes No Yes Are you getting Statutory Maternity Pay (SMP)? No Yes No Yes How much? When did it start? / / / / Do you pay into a private or No Yes No Yes company pension scheme? How much and how often? every every We need to see proof of earnings, Statutory Sick Pay or Statutory Maternity Pay etc. If you work for an empoyer, we can accept the foowing proof: Continued on the next page 11

12 Part 6: Your earnings (continued) Five of your most recent paysips if you are paid weeky, three if you are paid fortnighty, or two if you are paid fourweeky or monthy. We cannot accept hand written paysips. If you do not have any paysips you wi need to ask your empoyer to compete a certificate of earnings form. This form can be obtained from our website, or you may wish to contact us by teephone or at one of our offices. If you have ony recenty started a new job, pease provide a etter from your empoyer on headed paper giving detais of your expected earnings. You wi need to send paysips when you receive them to confirm your earnings. If you pay into a private pension scheme, we need to see a etter from your pension company confirming the pension scheme and evidence of the amount you pay, such as payments on your bank statement. A documents provided must be originas. We cannot accept photocopies. About any other work You Your partner Do you have more than one job? No Yes No Yes What is the name and address of your second empoyer? When did you start this job? / / / / How many hours do you normay work each week? hours hours How much are you paid? How often are you paid? (weeky, fortnighty, four-weeky, monthy) If you or your partner have more than two jobs, pease provide detais on a separate sheet of paper, and tick this box. Part 7: Other income you receive Do you or your partner receive any of the income types isted beow? No Yes You must fi in a the boxes. Pease write none if something does not appy to you or your partner. You Your partner How often? Works, occupationa or service pension When was your ast increase? / / / / Who pays you this pension? Private or other pension When was your ast increase? / / / / Who pays you this pension? Are you over 60 and have chosen to receive your works pension at a future date? No Yes No Yes When do you expect to receive this? / / / / Pease provide proof of how much you get and how often. If you are not sure what proof you can provide, pease contact us for advice. You do not need to te us about any payments you receive from the Eieen Trust, Independent Living Fund or the MacFarane Trust. A documents provided must be originas. We cannot accept photocopies. 12

13 Part 7: Other income you receive (continued) Maintenance for chidren Maintenance for yoursef Annuity or Home Income Pan Charitabe or vountary payments Councior aowances Training aowances Income from a trust fund Any other income Pease say where this income comes from You Your partner How often? If you receive any income from property or and you own pease ensure detais of this are incuded in part 10. You Your partner Does anyone owe money to you, No Yes No Yes your partner or any chidren you are caiming for? What for? How much? Are you expecting to get any No Yes No Yes money in the next 12 months? What for? (For exampe, a redundancy payment or a payment instead of notice or hoiday) How much? When do you expect to get this? / / / / We need evidence of a your income. These must be origina documents. Without these we cannot pay benefits. Part 8: About being a student You Your partner Are you or your partner No No a student? Yes Answer the questions beow. Yes Answer the questions beow. Is the course fu time Fu time Part time Fu time Part time or part time? What are the hours of study? How much is your student oan, grant or bursary for the academic year? When does the course Start / / Start / / start and finish? Finish / / Finish / / We need to see a etter from your pace of education confirming enroment and proof of your oan, bursary or grant. We wi accept a oan, bursary or grant award notice showing a breakdown of the award. 13

14 Part 9: About Bank/Buiding Society accounts, savings, investments and property You must te us about a your Bank or Buiding Society accounts, even empty or overdrawn ones. We aso need to know about any other savings you have invested, such as bonds, saving certificates, stocks and shares and unit trusts. Do you or your partner have any Bank/Buiding No Society accounts, savings, investments or property in the UK or abroad? Yes Answer the questions beow. Name of Bank/Buiding Society/ISA Account Number You Your partner Do you have any of the foowing? You Your partner Cash savings No Yes No Yes Premium Bonds No Yes No Yes Post Office accounts No Yes No Yes PEPs No Yes No Yes Money or property No Yes No Yes hed in trust Do you or your partner have any stocks, shares, bonds, unit trusts or Nationa Savings Certificates? No Yes Pease give detais beow. Stocks, shares, bonds and unit trusts Name of company Number hed Type (deete as appicabe) stocks / shares / bonds / unit trusts stocks / shares / bonds / unit trusts stocks / shares / bonds / unit trusts Nationa Savings Certificates Issue number Issue number Issue number Number of units Number of units Number of units If you need more space, pease use a separate sheet of paper, and tick this box. 14

15 Part 9: About Bank/Buiding Society accounts, savings, investments and property (continued) Other investments You Your partner How much is hed? Where is the money saved or invested? We accept the foowing as proof: Bank, Buiding Society and Post Office statements or passbooks, even if the account is overdrawn. These must cover at east the ast two months. We cannot accept baance sips showing the current amount. A etter from your Bank or Buiding Society. This shoud show the type of account hed, the account number, the current baance and detais of any transactions for the previous two months. For investments or other savings, such as unit trusts, savings certificates, stock and shares, bonds and so on, we need origina documents showing proof that you own them. A documents provided must be originas. We cannot accept photocopies. Part 10: About and and property Do you or your partner own any other property No or and besides the one you are caiming for? This incudes properties in this country and abroad. Yes Answer the questions beow. Pease confirm if this is a property or and Property Land What is the fu address of the property or and? Is the property or and up for sae? No Yes When did you put it on the market? Pease provide proof. / / What is the current vaue? Is the property or and mortgaged? No Yes How much do you owe on the mortgage? How much are the monthy mortgage payments? Pease provide proof. Is this property occupied? No Yes Do you receive any rent for the property? No Yes Pease provide proof. Amount How often? Pease give occupants names and reationship to you or your partner (such as parent, ex-partner, tenant). If a member of your famiy, is this person Over 60? Disabed? A documents provided must be originas. We cannot accept photocopies. 15

16 Part 11: About ump sum payments Have you or your partner received any of the foowing? You Your partner Far Eastern Prisoner of War Compensation Payment No Yes No Yes Compensation payment made to victims of atrocities that No Yes No Yes happened during the Second Word War Payment from the vcjd (Creutzfedt-Jakob disease) Trust No Yes No Yes Do any of your savings or investments incude: Money from the sae of a house? No Yes Money from a charity? No Yes Name of charity Part 12: About where you ive Amount Date received / / Amount Date received / / Who has to pay the Counci Tax bi for your home? (Tick the box that appies.) You or your partner Your andord Someone ese Te us who it is Do you own your home (or have a mortgage)? No You wi need to compete this part if you pay rent to a private andord, a housing association, or Curo Housing Group Ltd (even if you previousy rented this property from the Counci). Do you rent your home? No Tick Yes if you woud pay Yes Answer a the questions in this section. Your andord s and agent s fu rent but you aready get name and address must be decared. Faiure to do so wi resut in Housing Benefit. deay/oss of benefit. What is your andord s fu name and address? By andord we mean the person, or organisation who owns the property you ive in. Teephone If your andord has an agent, te us their fu name and address By agent we mean the person or organisation you actuay pay your rent to. Teephone Yes Have you or your partner (or chidren) ever been reated to, or in a reationship with your andord or agent (or their partners)? No Yes What is the reationship? Have you or your partner ever owned or part-owned the No Yes property you are renting? Do you have to rent your home as a condition of your empoyment? No Yes Are you iving in accommodation that is maintained by a reigious order? No Yes 16

17 Part 12: About where you ive (continued) How much rent are you charged? every (weeky, fortnighty, four-weeky, monthy) When did you start renting your home? (start of your tenancy) / / Has your rent been registered as a fair rent by the Rent Officer? No Yes Unsure Do you have a shorthod tenancy? No Yes How ong is your tenancy for? 6 months 12 months other (pease state) Are you a joint tenant? No Yes Pease te us who your joint tenants are beow. Do you have separate contracts? No Yes How much of the rent do you pay and how often? every Has your rent changed in the ast 12 months? When is the next rent increase due? No Yes (weeky, fortnighty, four-weeky, monthy) Send us proof of the date it changed and how much it changed. Do you have any weeks when you No Yes How many in a year? do not have to pay rent? Are you behind with your rent? No Yes By how many weeks? Does your rent incude money for any of the foowing? Meas No Yes How much? every For which meas (pease tick) Breakfast Lunch Evening mea Counci Tax No Yes How much? every Water authority charges No Yes How much? every Lighting No Yes How much? every Hot water No Yes How much? every Fue for cooking No Yes How much? every Laundry No Yes How much? every Ceaning room or windows No Yes How much? every Heating No Yes How much? every Persona care and support No Yes How much? every Garage or parking space No Yes How much? every Do you have to rent the garage as part of your tenancy agreement? No Yes How much? every Do you pay any service charges separate from your rent? For exampe, for ceaning or ighting in shared areas, an aarm system, a warden, genera counseing or support, meas, ift maintenance or Counci Tax? No Yes How much? every Pease te us the type(s) of services beow. 17

18 Part 12: About where you ive (continued) What sort of buiding do you ive in? (Tick one box ony.) Detached house Fat in a house Caravan, mobie home Semi-detatched house Fat in a bock Board and odgings Terraced house Fat over a shop Hote Maisonette Bedsit, rooms, or a studio fat Residentia nursing home Detached bungaow Hoste Other If you ive in a room what is the room number? If you ive in a houseboat what is the ength and beam? How many rooms are there? In the whoe house Just for you That you share with and your househod other peope Living rooms Bedsitting rooms Bedrooms Bathrooms and shower rooms Separate toiets Kitchens Other rooms Do you use your home for business? No Yes Pease ensure part 5 is compete. Do you have a main home somewhere ese? No Yes Te us about it beow. If your main home is somewhere ese in the UK or abroad, tick Yes, even if you do not pay rent for it. Do you pay rent on this home? No Yes How much? What is the address? Are you iving away from your usua home at the moment? No Yes Te us more about it beow. Why are you not iving at home? (For exampe, in hospita, prison, feeing domestic vioence, or your home is uninhabitabe.) When did you ast ive at home? / / When do you expect to go back home? / / What is the address of where you are iving at the moment? Have you subet your home? No Yes Who ives there now? Reationship to you Payment received every 18

19 Part 13: How you wi be paid and the choices you have Counci Tax Support wi be deducted from your Counci Tax iabiity. You wi be sent a revised bi. Some Housing Benefit tenants have a choice about how their Housing Benefit is paid. If you: rent from a housing association have a tenancy which started before 15/01/1989 ive in a hoste ive in exempt accommodation. (This appies to care/supervision provided by a vountary/charitabe organisation. This does not incude a andord who is providing care.) ive in accommodation where a substantia part of the rent is attributabe to board. (For exampe, bed & breakfast / hote tenancies.) You can either have benefit paid into your own Bank/Buiding Society account or direct to your andord. Pease choose either option 1 or 2 beow. For a other private tenants, benefit must be paid directy into your Bank/Buiding Society account, so you wi need to compete option 1. This is because your Housing Benefit wi be assessed under Loca Housing Aowance (LHA) rues. Pease see the next page for detais of when we can consider making payments direct to a andord or agent instead. Pease contact us for advice if you do not have a Bank or Buiding Society account that your benefit can be paid in to. Option for payment 1 Paid direct into your Bank This is a safe and easy way to get your Housing Benefit. or Buiding Society account In most cases, we wi pay your benefit every two weeks in arrears. Pease give the foowing detais Name and address of your Bank or Buiding Society Bank account number Buiding Society account number Bank sort code Pease te us a 6 numbers e.g Buiding Society ro number Type of Buiding Society account Name(s) of account hoder(s) (Pease write the name or names as they appear on the cheque book, passbook or statement.) 2 Paid direct to your This method is just as safe and easy as the first, but we wi pay your andord s Bank or Buiding Housing Benefit to your andord s account instead of yours. We wi write to Society account, if your your andord for their account detais. Benefit wi generay be paid four andord agrees to accept these weeks in arrears. arrangements 19

20 Part 13: Loca Housing Aowance (LHA) tenants ony If you have difficuty managing your affairs and woud ike payments of benefit made direct to your andord, pease answer the questions beow. About the person/organisation requesting payment of rent to the andord (if not the tenant). Name Organisation/reationship Address Teephone number The appication for payment of rent to your andord can be competed by the foowing: Tenant Landord/Letting Agent Famiy and friends Another service within the Counci Appointee Medica Professiona Advice or Wefare Agency If you consider that payments of Loca Housing Aowance shoud be made to your andord, pease tick the appropriate statement beow: Reason for paying LHA to the andord I have/my partner has probems managing my/our money because of earning difficuties I have/my partner has a medica condition or menta heath probem which makes it difficut to manage my/our money I have/my partner has serious difficuties reading and writing I have/my partner has difficuty speaking and understanding Engish I am/my partner is deaing with an addiction to drugs, acoho or gambing I am/my partner is escaping from domestic vioence I have/my partner has recenty been reeased from prison I am/my partner is an undischarged bankrupt I am/my partner is unabe to open a bank account I have/my partner has a history of rent arrears I am/my partner is homeess Proof we need to see Written proof from care workers or Socia Services Written proof from care workers, Socia Services, GP or hospita Written proof from support groups Written proof from support groups Written proof from support groups, Socia Services, GP or hospita Written proof from support groups, Socia Services, Poice Written proof from Probation Service, support groups, copy of the Court Order Letter from bank or money advisors Letter from bank or money advisors Proof of rent arrears, eviction etter Written proof from support groups, socia worker, homeess charity Other reason - pease te us about it beow. It is important that you provide cear written/documented evidence to support the information given on this form. However if it is obvious that no evidence is avaiabe, we can accept written testimonies from professionas, key workers, or any reevant third party. 20

21 Part 13: Paying benefit to your andord If you are asking us to pay your benefit straight to your andord, you must sign this decaration. Your decaration Pease pay my Housing Benefit straight to my andord. I understand that by aw: I must aways te you about any change in my circumstances. If I do not te you about any changes of circumstances and you pay me too much benefit because of this, I may have to pay back the overpaid benefit. That I may be prosecuted if I do not te you about any change of circumstances. Your signature Fu name (in CAPITAL LETTERS) Date / / Your andord s decaration I am wiing to accept Housing Benefit payments for the tenant named in this form. I understand that by aw: I must te you straight away if I find out about a change in the tenant s circumstances. You can stop paying benefit to me if I do not te you about any change of circumstances. I can be prosecuted if I accept Housing Benefit which I know I am not entitied to. 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 other tenants. This wi not affect their rent. Your andord s signature Fu name (in CAPITAL LETTERS) Date / / 21

22 Part 14: Permission to discuss Sometimes a andord or other third party may contact us about your caim, or on your behaf. If you ask anyone to contact us on your behaf, we wi not be abe to tak to them uness we aready have your permission to do so. If you do not wish us to discuss your caim with anyone ese pease tick here. Pease note - we may need to discuss payments with your andord if we are paying your Housing Benefit directy to them. If you give us permission to discuss your caim with your andord or andord s agent, pease tick here, and compete the foowing: Name of andord Name of agent/agency If you give us permission to discuss your caim with someone ese on your behaf, pease tick here, and compete the foowing: Name Organisation/reationship Address Teephone number Name Organisation/reationship Address Teephone number Name Organisation/reationship Address Teephone number 22

23 Part 15: Notes Pease use this space to te us anything ese you think we shoud 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, pease te us how many. You can aso use this space to te us about future changes to your circumstances that you know about now that may affect your caim for benefit. 23

24 Part 16: Backdating benefit We normay pay benefit from the Monday after we receive your caim. Sometimes we can pay from an earier date if you have good reasons why you have not caimed earier. If you want us to consider paying your benefit from an earier date, pease give as much detai in the box beow. If you do not provide sufficient reasons for your faiure to caim from the earier date, we may not be abe to backdate your benefit. Pease te us why you did not caim earier. Te us the date you want to caim from. / / 24

25 Part 17: Decaration Even if someone ese has fied in this form for you, you must sign this decaration if you are abe to do so. If you have a partner they do not have to sign this form, but getting them to do so shoud aow us to process your caim more quicky. Pease read this decaration carefuy before you sign and date it. I decare that the information I have given on this form is correct and compete. I understand that if I knowingy give information that is incorrect or incompete you may take action against me, and I understand that I coud be prosecuted. I agree that you wi use the information I have provided to process my caim for Housing Benefit or Counci Tax Support, or both. You may cross check the information with other sources within the Counci, rent offices and other councis. Data hed may be used in comparison for the purposes of prevention and detection of fraud. I understand that you may use any information I have provided in connection with this and any other caim for DWP benefit that I have made or may make. You may give some information to other organisations, such as government departments, oca authorities and private-sector companies, such as banks and organisations that may end me money, if the aw aows this. I know that I must et you know about any changes in my circumstances which might affect my caim as soon as they happen. I understand that if benefit is paid direct to my andord and a dispute arises over the amount paid, that you may have to discose a the detais of my caim and subsequent correspondence to my andord, their representative, and a court or an appea tribuna. Signature of person caiming Date / / Partners signature Date / / If this form has been fied in by someone ese other than the person caiming. Pease te us why you are fiing in this form for the person caiming. I decare that as far as possibe, I have confirmed with the person caiming that the answers I have written on this form are correct. Name of person who fied in the form Signature Reationship to the person caiming Organisation or contact number Date / / 25

26 Part 18: Checkist Pease check that you have answered a the questions that appy to you and remember to sign the decaration. If you do not have the proof we need at the moment, send the form back to us now and send the proof ater. We can start to process your caim, but we wi not be abe to pay you any benefit unti we have a the proof. You Your partner Have you answered a the questions No Yes No Yes Have you signed the form No Yes No Yes Pease tick to te us what you are sending with this form. Encosed To foow Encosed To foow Proof of identity and Nationa Insurance Number Proof of your rent Proof of a benefits Proof of wages Proof of a your accounts and savings Proof of a income for anyone ese iving in your home. Remember, if you do not provide a the information we have asked for on this form, we might not be abe to pay you any benefit. 26

27 Part 19: Contact information The best way to get advice or make a caim for Housing Benefit or Counci Tax Support is to visit Counci Connect in Bath, Keynsham or Midsomer Norton. Opening times of our offices may vary. Pease check at or ca To speak to someone about your caim during office hours, pease ca and seect the option for Benefits. Visit and foow the inks to Benefits. Customer Services PO Box 2797 Bath BA1 1WF 27

28 This form can be made avaiabe in a range of anguages, arge print, braie, on tape, eectronic and accessibe formats from Customer Services. Te: Fax Emai: Prepared by Bath & North East Somerset Counci s Customer Services and pubished by Bath & North East Somerset Counci s Print Services, Dartmouth Avenue, Odfied Park, Bath BA2 1AS DP /13 JM

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