APPLICATION FORM FOR HOUSING BENEFIT AND/OR COUNCIL TAX SUPPORT

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1 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 you supply must meet the standards stated on the checklist. On average 20% of all new claims received each year are unsuccessful because the application form has not been completed correctly or necessary documents are not supplied. You should return the application form to Mendip District Council as soon as possible. If you prefer you can have a meeting to process your application while you wait. To make an appointment please contact customer services on Please note that you will need to supply all necessary supporting evidence at the time of the meeting. The Benefits Section, Mendip District Council, Council Offices, Cannards Grave Road, Shepton Mallet, Somerset BA4 5BT. Telephone: Opening times: 8.30am 5.00pm (Monday to Friday) D12735

2 HOW TO FILL IN THE FORM Please fill in this form using black or blue ink. There are notes to help you on the next 2 pages. Please read these carefully Please answer all the questions on the form If you provide your daytime contact number or an address, we will be able to contact you by that method if we need to clarify any information, which could speed up your claim You must return this form to us immediately or at the latest within one calendar month of the date of issue even if you do not have all the proof we have asked for. If you delay in sending it or do not provide the missing proof within one calendar month of the date you return the form to the above address, you could lose benefit We can only accept original documents as proof. We cannot accept any photocopies Please return the completed form to the address shown on the front page DATA PROTECTION We will use the information you have given on this form and any supporting evidence to work out your Housing Benefit and Council 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 and Customs, as allowed by law. We may check the 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 information to them to: make sure the information is accurate prevent or detect fraud, and protect public funds These third parties include government departments, other local authorities and private sector organisations such as banks and organisations that may lend money including Credit Reference Agencies. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows. We are registered 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 your information you can ask the Council. 2

3 NOTES Please read these important notes before you fill in the form. They will help you to give us the right information so that we can pay your benefit quickly. There are notes for most sections, followed by some general information. A YOU AND YOUR PARTNER Partner means someone of the same or opposite sex that you live with as a couple; you may be married or in a civil partnership or living together as if you were husband and wife or as if you were civil partners. B CHILDREN WHO LIVE WITH YOU This would usually be your own children who are still at school, OR in further education and under 20. Adult children, or children who are in higher education (e.g. University), who still live with you should be included in Section C. Foster children should be included in Section C of the form. C OTHER PEOPLE WHO LIVE WITH YOU These people are often referred to as non-dependants. A non-dependant is someone who normally lives with the you on a non-commercial basis, for example, adult daughters, sons, other relatives and friends. A boarder is someone who lives with you and who has an agreement with you to pay for their accommodation. Part of what they pay will be for meals which are eaten on your premises. A sub-tenant is someone who pays you for accommodation, but whose rent does not cover any meals. A joint-tenant is someone (not your partner) who is jointly responsible with you for paying the rent at the property you live in. D EARNINGS If you cannot provide proof of your earnings, as detailed at the end of Section D, please use the Certificate of Earnings, supplied at the end of this form. If you have just started work and do not have any payslips, you can ask your employer to send us a letter telling us when you started work, what you will be paid, and how many hours you will work. You can send us your payslips as you get them. If you do send them in separately from your claim form, please ensure that your name, address and National Insurance Number are clearly shown. E SELF-EMPLOYED EARNINGS Where possible, you should send us properly prepared accounts. If you have not been self-employed for very long, or if for some reason you cannot provide accurate and complete accounts, we may have to send you another form to fill in. You can save time by ringing us and asking for this now, if you know that you will need it. F STUDENTS Many students are excluded from the benefit scheme. If you are not sure if you are eligible, please ring us, or send in the completed form for assessment G OTHER INCOME You should use this Section to list all other income you receive. You must answer every question. H CAPITAL, CASH, SAVINGS AND INVESTMENTS So that we can assess your benefit accurately, you need to tell us about all your capital which is held either here or abroad. Capital means bank accounts, building society accounts, deposit accounts with other organisations (e.g. Post Office or insurance companies), cash, National Savings Certificates, Premium Bonds, shares, stocks, unit trusts, PEPs, ISAs and TESSAs. Also any land or property which you own, apart from where you are living. We will also need to know if you have money in a trust fund. This is not meant to be a complete list - please telephone us if you have a query. If your total capital exceeds 16,000, you cannot claim Housing Benefit or Council Tax Support unless you or your partner are receiving Pension Credit Guarantee Credit. I YOUR TENANCY If you have lived in your property for a long time, you may have a Registered Rent. If so, please send us the documents that you will have been given by the Rent Service, and any letters from your landlord confirming the rent. 3

4 NOTES K YOUR RENT Your landlord should have made clear to you whether or not any services are included within your rent and you should give as much detail here as you can. If you cannot give us exact figures, we will have to make standard deductions which are laid down by central government, or we may have to contact your landlord. L PAYMENT Housing Benefit for private tenants is normally paid fortnightly in arrears. If payment can be made to your landlord it will be 4 weekly in arrears. Housing Benefit will usually be paid direct into your bank account. Council Tax Support will be shown as a discount on your Council Tax Bill. SECOND ADULT REBATE Second Adult Rebate can only be claimed if you are of pension age from April If you are of pension age and your income or capital is too high for you to claim benefit yourself, you could get Second Adult Rebate. To qualify, you must be the only person in your home responsible for paying Council Tax and someone else must live with you who is not your partner AND who is on a low income AND who does not pay rent to you. If you want to claim Second Adult Rebate, you only need to complete Sections A and C, provide proofs, and sign the Declaration. VISITS We may visit you at home. This is to make sure that you are still getting the right amount of benefit. All of our Visiting Officers carry photo identity cards. Please make sure that you ask to see this before you let anyone into your home. WHY DO WE NEED ORIGINAL DOCUMENTS? The documents that we require to support your claim are recommended by the Department for Work and Pensions (DWP). Providing these proofs helps us to make sure you receive the benefits that you are entitled to and that they are calculated accurately. You can check the types of documents that we can accept against the checklist later in this form. DON T DELAY You will see reminders on the form that you must send us original proofs, not photocopies and that we cannot process your claim until we have seen ALL of the documents. We understand that it is not always easy to get them to us straight away, so even if you haven t got everything, send us the form. If you don t you could lose benefit. CHANGES OF CIRCUMSTANCE We use the information you have given us on this form to assess your claim. You MUST tell us in writing about anything that changes and provide original proof of this change. Later in this form is a list of some of the changes that you need to tell us about. You can contact this office via telephone , visiting one of our Council Access Points or by letter addressed to the Benefit Section. 4

5 PLEASE PROVIDE THE FOLLOWING INFORMATION ARE YOU A (tick one box only) Private Tenant? Housing Association Tenant? Owner Occupier? WHICH TYPE OF BENEFIT DO YOU WISH TO CLAIM? Housing Benefit Council Tax Support Second Adult Rebate A YOU AND YOUR PARTNER * Please see notes. If you do not have a partner tick this box Surname Other names Title Other National Insurance Date of Birth Please tell us if there are any other names you use, or are known by YOU Mr Mrs Miss Ms YOUR PARTNER Mr Mrs Miss Ms Address you wish to claim for Postcode Telephone Are you currently resident? If no, why and the date you expect to move in? If yes, what date did you move in? Do you own or have you previously owned this property? Are you a joint owner or joint tenant? If YES, who with? What is your nationality? Have you lived in the UK for the whole of the last 2 years? If no, please give the date that you arrived in the UK (we may need to write to you for more details) (we may need to write to you for more details) Are you eligible to claim benefit in the UK? (for n-uk passport holders see visa entry conditions in your passport) 5

6 A YOU & YOUR PARTNER (cont) YOU YOUR PARTNER What was your last address? Please tell us the date you vacated this address If this is different from the date you occupied your current address please state why Did you own this property? Did you rent this property? Were you living with relatives at this address? Have you received Housing Benefit or Council Tax Support within the last 52 weeks? Are you under 35, single, with no children? Have you had support from Social Services after your 16th birthday? Have you ever been in prison or a specialised hostel? Do you have a non-resident overnight carer? If YES, we may need to contact you further DISABILITY PREMIUMS Do you receive a disability premium or allowance? Have you been unable to work for more than 52 weeks through ill health? Are you registered blind? If YES, please give your registration number Does anyone get Carer s Allowance for looking after you? If YES, please say who gets it Please send ORIGINAL proofs of identity and National Insurance Number for yourself, and your partner if you have one. See the checklist for examples of the documents you could use. PLEASE REMEMBER YOU MUST PROVIDE PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES. 6

7 B CHILDREN WHO LIVE WITH YOU * Please see notes If there are no children who live with you, tick this box and go to section Do you or your partner receive Child Benefit for any children who live with you? If you have more than 3 children, please use the extra box at the bottom of the page to tell us about them. If you have other children who live with you, but you don t get Child Benefit for them, please include them in Section C C 1st Child 2nd Child 3rd Child Surname Other names Date of birth What is their relationship to you? Are they male or female? Are they in full time education? Are they registered blind? Do they receive Disability Living Allowance? Do they go to a registered nursery, childminder or playscheme? If yes, please give the name and address of the childminder, nursery or playscheme caring for each child What is their registration number? What is the weekly cost of childcare for each child? For each child, please send ORIGINAL proofs of Child Benefit, any childcare costs, Disability Living Allowance and/or blind registration document. Please refer to checklist PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES. More details 7

8 C OTHER PEOPLE WHO LIVE IN YOUR HOME * Please see notes Apart from you, your partner and your dependent children, does anyone else live in your home? D If NO, please go to section If YES, please give details below. You should include children who you no longer get Child Benefit for, friends, relatives, boarders, sub-tenants or joint-tenants. Please continue on a separate sheet if the space provided here is not enough. Surname 1st Person 2nd Person 3rd Person Other names Date of birth National Insurance. Date they moved in What is their relationship to you? Are they a joint tenant or joint owner? Do they pay you any rent? If YES, how much and how often? per per per Go to Section D if you only have Joint Tenants living with you Does their rent include payment for meals? Does their rent include payment for heating/hot water? Do they receive Income Support or Jobseeker s Allowance (income based)? Do they get any other state benefits? If YES, please state amount, how often and which one(s) they receive per per per Do they work? If YES, how many hours per week? What are their earnings before tax and National Insurance etc? per per per Do they have any other income? If YES, please state amount, how often and give details of what it is per per per Do they provide care for someone in your home for more than 35 hours per week? If YES, who do they provide the care for? What is their relationship to this person? Are they a Student? (please supply proof of their course) 8

9 C OTHER PEOPLE WHO LIVE IN YOUR HOME (cont) 1st Person 2nd Person 3rd Person Are they severely mentally impaired? Are they in prison or in hospital? If YES, please give the date that they went into prison or hospital Are any of the people married, civil partners or living together as if they were married or civil partners? If YES, please say who: D EARNINGS is the partner of is the partner of For each person, please send ORIGINAL proofs for all of their income or benefits. PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM, WE CANNOT ACCEPT PHOTOCOPIES. If you only wish to claim Second Adult Rebate, go to the declaration at section M * Please see notes.. For an explanation of Second Adult Rebate please see the notes. YOU YOUR PARTNER Are you in paid employment? If NO, go to section E If YES, please give details below Employer s name and address What is your employee/payroll number? What is your job title? Date you started this job Is your job seasonal or temporary? If YES, when will it end? How many hours each week do you work? How much are you paid after deductions? How often are you paid? How are you paid? (e.g. weekly, 4-weekly, monthly) (e.g. cash, cheque, direct into bank) (e.g. weekly, 4-weekly, monthly) (e.g. cash, cheque, direct into bank) Do you regularly work overtime? Do you receive bonus, tips or commission? If YES, please state when your bonus/ commission is paid and how much you receive 9

10 D EARNINGS (cont) YOU YOUR PARTNER Expected date of next pay rise Do you pay into a Pension Scheme? If how much? per per If YES is it: Company Private Company Private Do you have more than one job? If YES, please give details here of the employer, the hours you work and how much you earn. Do you receive Statutory Adoption Payment? Do you receive Statutory Sick Pay? Do you receive Statutory Maternity Pay? Do you receive Statutory Paternity Pay? Please continue on a separate sheet if the space provided here is not enough. Please continue on a separate sheet if the space provided here is not enough. For each job that you and your partner have, you must send ORIGINAL proofs. Please supply your last 5 payslips if you are paid weekly, your last 3 payslips if paid fortnightly, your last 2 payslips if paid monthly or 4-weekly. Alternatively, you can provide your contract of employment or complete the certificate of earnings at the back of this form. PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES. E SELF EMPLOYED EARNINGS * Please see notes. Are you self employed? If please go to section F. If please give details below. We may need to write to you for more information. If please complete section Are you a Director/Secretary of any company? The name of your business The address of your business D YOU YOUR PARTNER Business Telephone Number What type of business do you run? When did you start trading? What is the financial year start date? What is your current estimated weekly profit? How many hours each week do you work? Are you a partner in the business? Do you pay into a Pension Scheme? You must send ORIGINAL proofs, not photocopies. Please supply your latest accounts. If the business is new, please send any details that you have, and give an estimate of your income and expenditure. If you do not have this information please contact the Benefit Section for the appropriate form. If you pay into a Private Pension Scheme, please send evidence of the payments you make. We may ask you to complete a further form. 10

11 F STUDENTS * Please see notes. Are you a student? Is your partner a student? If please go to section. If please give details below. G YOU YOUR PARTNER Are you studying Full time Part time If you are studying part time, Please state the number of hours Full time Part time Name of college/university Title of Course Length of Course Which year of study are you in? Final 1st 2nd 3rd 4th year Final 1st 2nd 3rd 4th year Term time dates: Autumn to Spring Summer to to Do you receive a Student Grant? If yes, amount and how often paid every every Do you receive a Student Loan? If yes, amount and how often paid every every Are you on a sandwich course? Do you receive sponsorship? Do you receive a convenant? Do you receive parental contribution? Do you have any other income? Do you receive a scholarship, studentship or any other educational award? If, to any of the above please give details 11 Do you have any incurred or intended expenses relating to your course attendance? If yes please provide details in the further information section on page 18 along with supporting evidence You must send ORIGINAL proofs for you and your partner. Please supply your grant notification, if you get one, your financial assessment letter and proof of all student loans. We will also need to see evidence of any covenants, sponsorships or scholarships etc. PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES.

12 G OTHER INCOME * Please see notes. Please answer ALL the questions in this section. Where you do receive them, please write the amount you get before any deductions. (You do not need to declare any payments from The Eileen Trust, Independent Living Fund or the MacFarlane Trust.) If you are getting INCOME SUPPORT, JOB SEEKERS ALLOWANCE (Income Based) or GUARANTEE PENSION CREDIT, Please tick this box and go to section. I Do you receive any Pensions? If yes, please confirm the amounts below State Retirement Pension Occupational/Private or Superannuation Pension Company Name Please state when you are due to receive an increase to this pension Widowed Mother s or Parent s Allowance War Widow s or War Widower s Pension Industrial Widow s Pension War Disablement Pension Armed Forces Compensation Scheme Pension Credit (Guarantee Credit) Amount YOU How Often YOUR PARTNER Amount How Often Pension Credit (Savings Credit) Do you receive any Benefits and Allowances? If yes, please confirm the amounts below Income Support Jobseeker s Allowance (income based) Jobseeker s Allowance (contribution based) Child Benefit Working Tax Credit Child Tax Credit Short-term Incapacity Benefit Long-term Incapacity Benefit Employment and Support Allowance Work Related Activity Component Support Component Attendance Allowance Universal Credit Personal Independence Payment 12

13 G OTHER INCOME (cont) YOU YOUR PARTNER Amount How Often Amount How Often Disability Living Allowance: Mobility Component Care Component Carer s Allowance Severe Disability Allowance Industrial Injuries Benefit Education Maintenance Allowance Maternity Allowance Fostering/Adoption/Guardians Allowance Do you receive any Other Income? If yes, please confirm the amounts below Earnings Protection Payments Mortgage Protection Payments Any Government Training Allowance Return to Work Credit Maintenance you receive for yourself/partner Maintenance you receive for children Trust Income received Weekly amount from letting or sub-letting part of a property other than the home in which you live Annuities Payments from a charity or other voluntary payments Any other income (please give details) Have you or your partner recently applied for any benefit or income but have not yet received payment? Please tell us which benefit or income What date did you claim it? Maintenance Payments Do you or your partner make a formally assessed parental contribution to children who are students in full-time higher education? Amount Period Covered If, please give details (Please provide the grant notification). Please supply ORIGINAL proofs of all income received by you and your partner, if you have one. PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES. 13

14 H BANK/BUILDING SOCIETY ACCOUNTS, SAVINGS AND INVESTMENTS * Please see notes. You need to tell us about all your bank accounts, including any current accounts, building society accounts and Post Office accounts (even if they are overdrawn) and all other cash and investments. You must send current statements or passbooks showing all transactions for the last 2 months. Please note that mini statements will not be accepted. Do you have any bank or building society accounts or other savings or capital? Does your partner have any bank or building society accounts or other savings or capital? Name of Bank/Building Society/PO Account. Amount held In the name of You Partner Joint You Partner Joint You Partner Joint You Partner Joint You Partner Joint You Partner Joint Type of Capital Description Amount held In the name of Do you have any Savings or Investments? You Partner Joint National Savings Bonds You Partner Joint National Savings Certificates You Partner Joint Income Bonds You Partner Joint Shares or Unit Trusts You Partner Joint Stocks, Sharesave, SAYE etc You Partner Joint Cash savings You Partner Joint Premium Bonds You Partner Joint Other You Partner Joint Do you or your partner have any other savings, investments or money owing to you which you have not included in the lists above (such as PEPs, ISAs, personal loans)? If YES, please give details Do you, your partner or any of your children have any money or property held in a trust fund? If YES, please give details and let us see the documents Are you, your partner or any of your children a beneficiary of a Will which has not yet been settled? If YES, please give details and let us see the Will 14

15 H BANK/BUILDING SOCIETY ACCOUNTS, SAVINGS AND INVESTMENTS (cont) Do you or your partner own any property other than the home you live in? If, please tell us the address, value of the property and balance of any loan secured against it together with supporting documentary evidence. Address Approximate Market Value Please supply supporting evidence Outstanding loan or mortgage Please supply supporting evidence Is the property for sale? If, send proof If no please confirm the reason in the further information section on page 18 along with supporting evidence Is the property occupied by your former partner who is now a lone parent? If yes please provide details of the occupiers in the further information section on page 18 Does a member of your family live in this property? If, is this person over 60? Or is that person incapacitated? Do you or your partner own, either by yourselves or jointly with others, any:- land, property, or valuable objects, or have interests in business/es, or have any other capital, savings, or investments? If, please give details and their estimated value I YOUR TENANCY I J K L * Please see notes. You should only fill in Sections and if you pay rent to a private landlord, Housing Association or Registered Social Landlord. If you are an owner-occupier or not liable to pay rent go to the Declaration at Section When did your tenancy start at your current address? Landlord s name Landlord s address M Landlord s telephone number If the landlord has an agent you also need to tell us Agent s name Agent s address Agent s telephone number Are you, your partner, or any of your own or your partner s children related to your landlord or agent, or to your landlord s partner or the agent s partner? If YES, who is related and what is the relationship? Is your property part of a shared ownership scheme? Have you signed a tenancy agreement? How long is it for? Months What kind of tenancy is it? Assured Shorthold Other (please state) Don t know Has your rent been registered by the Rent Officer as a fair rent? Don t know (If YES, please send the registration form) Do you authorise the Council to discuss all aspects of your claim with your landlord? 15 Please send ORIGINAL proofs of your tenancy. You should supply your tenancy agreement OR a letter from your landlord stating your rent and frequency, any services included and the date your tenancy started. Please note that a tenancy agreement must be signed by landlord or agent and any letter must be signed by your landlord. Alternatively, please complete the certificate or rent at the back of this form. PLEASE REMEMBER YOU MUST SEND PROOFS TO AVOID DELAYS IN ASSESSING YOUR CLAIM. WE CANNOT ACCEPT PHOTOCOPIES.

16 J YOUR HOME You should only fill in the Sections and if you pay rent to a private landlord, Housing Association or Registered Social landlord. If you are an owner-occupier or not liable to pay rent read and sign the Declaration at Section Please tick only one box that best describes your home House Maisonette Bungalow M J K L Please tell us the number of each type of room in your home, and who uses them Living rooms How many in the whole house or flat? How many are only used by you & your family? How many do you share with other people? Converted Flat Flat over a shop Purpose Built Flat Studio Flat Bedsit Rooms in a house or hostel Mendip District Council B&B Other (please give details - we may need to write to you) Bedrooms Bedsitting rooms Kitchens Bathrooms Toilets Other rooms (please specify) How many floors are there in the whole building? Which floor is your home on? Is the property you live in Detached? Semi-detached? Terraced? If you rent a room, please tell us the room number Where is your room? (tick one only) At the front of the property In the centre of the property At the back of the property Do you share your room with anyone? Does your landlord live in the property? 2nd Floor 1st Floor Ground Floor Basement Is there central heating in your home? Do you have use of a garage? If, does it form part of the tenancy? Is your accommodation: Other (please specify) Fully Furnished? Partly Furnished? Unfurnished? Who is responsible for decorating the inside of your home? You Landlord Unknown 16

17 K YOUR RENT * Please see notes. How much rent does your landlord charge you? Is this every Day? Week? Fortnight? 4 Weeks? Calendar Month? Quarter? Do you have any rent-free weeks? When are they? Are meals included in your rent? Which ones? Breakfast? Lunch? Evening Meal? Are you in arrears with your rent? If, state how much and the period covered If you know in advance when your rent is due to be increased, please confirm the date Does the rent you pay include any of these charges? If YES, please tell us how much (if you know). We may have to write to you or your landlord for further details. Lighting Water Rates per (of YOUR rooms) per Council Tax per Heating (of YOUR rooms) per Hot Water per Fuel for Cooking per Laundry per Cleaning per Garage per Any other Services? If YES, please give details Do you pay any service charges separate from your rent? If YES, please give details and amount paid per L PAYMENT * Please see notes Tenants getting Local Housing Allowance (LHA) Your benefit will be paid directly to you. If you feel this may cause you difficulty, please contact the Benefit Section for advice. Housing Association and Tenants exempt from LHA You can have payments made to you or your landlord if you prefer. Do you want your Housing Benefit to be paid to you? Or to your landlord? Or to the landlord s agent? Please give details of the account you would like your benefit paid into Name of the Bank or Building Society Branch Sort Code Account Name Account Number 17 Roll Number (Building Society accounts only) w please read the checklist. Read and sign the declaration on Page 18 and then return the form to us, along with your ORIGINAL documents. IF YOU DO NOT HAVE ALL THE PROOFS WE NEED, RETURN THE FORM IMMEDIATELY AND PROVIDE THE PROOFS WITHIN THE SPECIFIED TIME LIMITS. IF YOU DELAY YOU MAY LOSE BENEFIT.

18 FURTHER INFORMATION Please use this section if you need more space to answer any questions or to tell us anything else you think we may need to know to process your claim. We usually pay Housing Benefit and Council Tax Support from the Monday following the day we receive your claim. Sometimes we can pay your benefit from an earlier date if you have good reasons for not applying sooner. If you would like us to consider your claim from an earlier date, please confirm the date you would like benefit considered from and why you did not apply at the time. Date you want to claim benefit from / / Reasons for not applying at the correct time Sharing information with third parties could help us deal with your claim more quickly and reduce the risk of you falling behind with your rent. Under the Data Protection Act 1998 we need your permission to discuss your claim with anyone else. If you want to give us permission to discuss your claim with third parties, please sign below. I give Mendip District Council permission to share information connected with the progress of my benefit claim with the understated (e.g. landlord, Citizens Advice Bureau). Signature Date M DECLARATION SPECIAL NOTICE The Authority is under a duty to protect the public funds it administers and to this end may use the information you have provided in this form within this Authority for the prevention and detection of fraud. It may also share this information with other bodies administering public funds solely for these purposes. DECLARATION Please read carefully the declaration below before signing the form. I declare that the information given on this form is true and complete to the best of my knowledge I authorise the Council to make any checks i.e. data may be checked against other information or passed to other public bodies for verification such as DWP agencies I agree to inform the Council s Benefits Section immediately of any changes in circumstances I understand that any false information given for the purpose of obtaining benefit will make me liable to prosecution, and any overpayment will be recovered from me Signature of person claiming Date Partner s signature THIS FORM WHEN COMPLETED SHOULD BE RETURNED TO THE ADDRESS ON THE FRONT. YOU MAY LOSE BENEFIT IF YOU DO NOT SEND IN YOUR FORM NOW. IF YOU HAVE NOT HEARD FROM US WITHIN 14 DAYS, PLEASE CONTACT US IMMEDIATELY. Please send in your form as soon as you complete it, even if you do not have all the proof. Send in the rest of the proof within the time scale specified on page 2 to ensure you get all the benefit to which you are entitled. Form filled in by someone other than the person claiming Please tell us why you are filling in this form for someone else. Date Name of the person who filled in the form Signature of person Date Relationship to the person claiming I have confirmed with the person claiming that the answers on this form are correct I have confirmed with the person claiming that they understand the declaration they are signing 18

19 N ETHNIC MONITORING We need to monitor the ethnic groups who apply for benefit to ensure that we are meeting the needs of our customers. It would be helpful if you could complete the following information: What is your ethnic group? (Please tick the appropriate box) A. WHITE: British Irish Any other white background Please state B. MIXED: White and Black Caribbean White and Black African White and Asian Any other mixed background Please state C. ASIAN or BRITISH ASIAN: Indian Pakistani Bangladeshi Any other Asian background Please state D. BLACK or BLACK BRITISH: Caribbean African Any other Black background Please state E. CHINESE or ETHNIC GROUP Chinese Any other Please state Do not wish to answer Your name Your address Your reference number 19

20 CHECKLIST Documentary evidence required to support your application. Identity only originals are acceptable. To prove your identity, you must provide two documents from the following list. If you have a partner living with you, they must also provide two documents: Passport National ID Card Any Home Office document that includes your photograph Driving licence Birth, adoption or marriage certificate Divorce or annulment papers National Insurance Number card Medical card with NHS number Bank statement or building society passbook A letter from a solicitor or social worker or probation officer confirming how long they have known you A current benefit book or notification of award with National Insurance Number Form B79 tification of discharge from prison Disability Freedom Pass Valid UK residence permit Life assurance or insurance policy documents Tax certificate or a letter from Her Majesties Revenue & Customs Utility bill National Insurance Number only originals are accceptable National Insurance Number card Any form of income proof containing the National Insurance Number If you have a partner they must also provide proof of their National Insurance Number. Earnings only originals are acceptable Any one of the following is acceptable: 5 recent consecutive printed weekly wage slips 3 recent consecutive printed fortnightly wage slips 2 recent consecutive printed monthly or four weekly wage slips slips Certificate of earnings properly completed and stamped by your employer. Please detach and use if required Contract or letter of employment Childcare Payments only originals are acceptable Proof childminder is registered and Receipts for childcare payments made or Letter from childminder confirming weekly/monthly payments Childminding contract confirming set charges Invoices Self Employed Earnings only originals are acceptable Profit and loss accounts supported by bank statements and a sample of invoices and receipts Benefits and Pensions only originals are acceptable A typed letter from the Department for Work and Pensions confirming benefit entitlement for the current financial year, supported by proof of the benefit you receive i.e. a current bank statement showing the appropriate entry Pension Credit award letters A private pension payment advice slip showing the rate of pension you currently receive Current bank statement showing the private pension payment being received, supported by a typed award notification letter for the current financial year Other Income only originals are acceptable If you receive any other income you must provide proof of it. Examples of other income include Child Tax Credit, Working Tax Credit, maintenance payments, annuities and rent from a subtenant or lodger. The following are acceptable as proof: Tax Credit award letters For maintenance payments, annuities and rent from a subtenant or lodger, a letter from the person or company paying the income Capital, Savings and Investments only originals are acceptable Current consecutive bank or building society statements covering at least 2 months showing all transactions Savings book updated within the 2 months immediately before the date of the benefit claim Original certificates showing ownership of premium bonds, unit trusts, National Savings, stocks and shares Please note evidence is not required if the total value of yours and your partners savings and investments is less than Rent only originals are acceptable Tenancy agreement signed by landlord or agent Signed letter from the landlord Rent proof must state: the amount of the rent how often the rent is charged what services are included the date the agreement started the landlord s name the name and address of any agent The income of other people living with you Anyone living with you, aged 18 or over, who is not a sub-tenant, lodger or joint tenant should provide proofs to the standard above. If you are unable to provide this information please contact the Benefit Section for advice. We would recommend that you send any valuable documents by a secure method. Any documents sent to us by Recorded Delivery will be returned in the same manner. 20

21 CHANGES YOU MUST TELL US ABOUT We will assess your claim using the information you have given to us. You MUST tell us straight away if there are any changes to your circumstances. Here are some examples of changes you must report. You stop receiving Income Support or Job Seekers Allowance Your Working Tax Credit or Child Tax Credit changes You move (even if you only move to a different room or flat within the same property) A child leaves school or leaves home You have a baby Your child starts to be cared for, or stops being cared for, by a registered childminder, nursery or playgroup Someone moves into or out of your home (including boarders and sub-tenants) Your income, or the income of anyone living with you, goes up or down You or anyone living with you becomes a student or takes up a Government Training Scheme You or anyone living with you goes into hospital, a nursing home or goes into prison (even if this is on remand) You or anyone living with you gets a job, changes their job, becomes unemployed or changes the number of hours they work You or anyone living with you takes on a second job You return to work after a period of illness You or anyone living with you has a change in capital or savings (this does not apply to people receiving Pension Credit (Guarantee Credit) - you should notify the Department for Work and Pensions) Your rent changes You and/or your partner will be away from home for 13 weeks or more. Where possible, tell us about this BEFORE you go You receive a decision from the Home Office Someone starts to receive Carer s Allowance for looking after you If you change the bank account that we are paying your Housing Benefit into If your total capital and savings increases to 6000 or more (this does not apply to people receiving Pension Credit (Guarantee Credit) - you should notify the Department for Work and Pensions) ANYTHING AT ALL which is different from what you have told us on this claim form You must tell us about these changes in writing - a phone call is not always enough. Do not rely on anyone else to give us the information or pass a message on, not even the Job Centre Plus, Pensions Service or Her Majesty s Revenue and Customs. If you don t tell us about the changes you may lose money you are entitled to or we may pay you too much benefit which we can ask you to repay. FURTHER INFORMATION Please use the space on page 18 to tell us about anything else you think we need to know to help us to deal with your claim. 21

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23 EMPLOYERS CERTIFICATE OF GROSS EARNINGS PRIVATE AND CONFIDENTIAL TO THE APPLICANT Enter your name, occupation and works number on this form before handing it to your employer. When completed please return this to the Benefits Section. Further copies of this form are available. Applicant s Name & Address Is the employee contracted out of the National Insurance scheme? OCCUPATION WORKS NUMBER TO THE EMPLOYER Mendip District Council would be grateful if you could complete this certificate and return it to your employee. Please give details below of the last 5 weekly, 3 fortnightly, 2 four weekly or 2 monthly earnings AND the gross to date figures. Thank you for your co-operation. Employee s National Insurance Number Employee s Current Tax Code Please tick if paid:- Weekly Calendar 4 Weekly Fortnightly Monthly Please tick if paid by: BACS Cash Cheque Date Employment commenced Average Hours Worked per Week? Date of last pay rise REMARKS Please indicate any week during which pay was lower or higher than normal because of sickness, bonus, pay rise etc. If figures provided are not representative please provide pay details for a longer period. Date of next pay rise Week/Month Ending Please state date Week/Month One Week/Month Two Week/Month Three Week/Month Week/Month Four Five Gross to date Office Use Only Gross Pay Inc. bonus, overtime, sick pay etc National Insurance Income Tax Superannuation/Pension Tax Code Used Average Weekly/Monthly Bonus if not included above Signature Of Employer OFFICIAL BUSINESS STAMP Business Address Telephone. Date All evidence must be ORIGINALS. Photocopies will not be accepted. Please refer to checklist on page 20 to see what evidence is required. Failure to provide this information within one calendar month may result in you not being entitled to benefit. 23

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25 CERTIFICATE OF RENT PRIVATE AND CONFIDENTIAL If you do not have a tenancy agreement or sufficient evidence of rent (see checklist) please use this certificate. This form MUST be completed in full by the landlord, an agent or third party acting on his or her behalf, not by the tenant. Full name of tenant Or full names of all joint tenants Address of tenancy (Please include any room number) Date tenancy started Has the rent increased since the start of the tenancy? When did the last rent increase start? How much is the total rent? How often is this amount payable? Are there any rent free weeks? Period of notice required from tenant Does the rent include any of the following? (Please answer or to each item). If the answer is yes, please enter the weekly amount. or Amount or Amount Council Tax Lighting Water Rates Fuel for cooking Heating of room(s) Laundry Cleaning of room(s) Other Rent free weeks Please give details of other Does the rent include meals? If yes, which meals are included? Is an agent or third party acting on behalf of the landlord? If you answered yes then below you must supply full details of the agent or third party AND the landlord. If you answer no then below you must supply full details of the landlord. Name of agent / third party Address of agent / third party Agent / third party telephone number 25

26 CERTIFICATE OF RENT (cont) PRIVATE AND CONFIDENTIAL Name landlord Address of landlord Landlord telephone number Is the landlord related to any of the tenants or tenants household members? Name of household member to whom the landlord is related? What is the relationship? Who owns the property detailed overleaf? DECLARATION This form has been completed in full by myself in the capacity of Landlord/Agent/Third Party (please delete as appropriate). I declare that the information given on this form is, to the best of my knowledge, correct and complete. I understand that if information given on this form is deliberately incorrect or incomplete it is a criminal offence and action may be taken against me. I undertake to immediately inform the council of any changes in circumstances of my tenants which may affect their benefit entitlement. Signature Date Please print name Please return this form to The Benefits Section, Mendip District Council, Council Offices, Cannards Grave Road, Shepton Mallet, Somerset BA4 5BT. Telephone: Opening times: 8.30am 5.00pm (Monday to Friday) 25 26

27 NOTIFICATION OF CHANGE IN CIRCUMSTANCES TO BE USED WHEN YOUR CIRCUMSTANCES CHANGE This form is provided so that you can notify the Council of any change in circumstances that might affect your benefit and/or support. CLAIMANTS ARE REMINDED THAT IT IS THEIR DUTY TO NOTIFY ANY CHANGE IN CIRCUMSTANCES IMMEDIATELY. Failure to do so within one month of the date of the change, where the change would increase the benefit, will result in the loss of benefit. Examples of these changes are shown on the checklist, BUT as the list is not a full list of all the relevant changes in circumstance, you should ensure that ANY change in circumstances in respect of you or your household is notified to the Council. Your Full Name Your Address Please tick box/es to show if you are due to pay Rent to a Housing Association or Registered Social landlord Rent to a Private Landlord Your Ref.. Council Tax Date of change in circumstances: Details of the change in circumstances: PLEASE ENCLOSE DOCUMENTARY EVIDENCE WHERE APPROPRIATE - Please see the checklist for examples of proof required. I declare that to the best of my knowledge the information given is true and complete and my circumstances remain the same other than that stated above. I authorise the Council to make any enquiry to verify the information if they wish to do so. I confirm other than the changes notified all other circumstances remain the same. Warning: To give false information or to withhold information may result in prosecution. Signature Date FAILURE TO NOTIFY A CHANGE IN CIRCUMSTANCES PROMPTLY MAY RESULT IN AN OVERPAYMENT WHICH YOU WILL HAVE TO REPAY. Please return this form to The Benefits Section, Mendip District Council, Council Offices, Cannards Grave Road, Shepton Mallet, Somerset BA4 5BT. Telephone: Opening times: 8.30am 5.00pm (Monday to Friday) 27

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