Blue Badge Application Form Providing accessible parking for disabled people

Transcription

1 Blue Badge Application Form Providing accessible parking for disabled people If you need help filling in this form please us at call into your local One Stop Centre, or contact us on You can also apply online for a blue badge. For further information please visit our website at If your application for a blue badge is successful, you will also qualify for a bus pass. This will be sent separately to your blue badge. If you are 65 or over you are already entitled to a Senior Travel Pass, you can get this pass from any WY Metro bus station travel centre. If you are eligible for a Senior Travel Pass you will not be sent a Disabled Bus Pass as both give the same fare concessions. Your application - please tick the appropriate box I have not had a blue badge before I currently have a blue badge that is due to expire If you currently have a blue badge please provide the following: Serial No Expiry date Which local authority issued this badge? If your blue badge has already expired please return it with this application form Terminal illness A person with a terminal illness is someone who is not expected to live beyond 12 months. If you have a terminal illness please tick here If you have ticked this box, please send a supporting letter from your doctor or specialist, such as a MacMillan nurse. You do not need to pay for your blue badge. You do not need to complete sections A and B but please complete C in full.

2 Part A Eligibility criteria eligible without further assessment Please indicate which criteria applies to the applicant and provide a copy of the proof requested. I am registered as severely sight impaired (blind) Proof: Copy of CVI Certificate Please note if you are already registered with Leeds City Council as severely sight impaired, you do not need to send this proof document. You will need to pay the fee for your blue badge. I receive the higher rate mobility component of the Disability Living Allowance Proof: Copy of letter of entitlement dated within the last 12 months showing your full name and current address as well as the start and end date of your benefit. If you do not have this letter, please call DWP on to request a copy of your 384 entitlement letter. You will need to pay the fee for your blue badge. I am in receipt of P.I.P and have been awarded 8 points or more in the moving around category Proof: A full Copy of the award letter of entitlement dated within the last 12 months showing moving around points awarded and your full name and current address as well as the start and end date of your benefit. You will need to pay the fee for your blue badge. I receive a War Pensioners Mobility Supplement (WPMS) Proof: Copy of your letter from the Service Personnel Veterans Agency (SPVA). If you do not have this letter please call SPVA on You do not need to pay for your blue badge I have been awarded a benefit under the Armed Forces Compensation Scheme (AFCS) and are in receipt of tariffs 1-8 under the Armed Forces and Reserve Forces Compensation Scheme Order 2011, having been assessed as having a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking Proof: Copy of award letter from the SPVA. If you do not have this letter please call SPVA on You do not need to pay for your blue badge

3 Part B Eligibility criteria eligible subject to further assessment. Important notes for Part B please read before completing. If you have not ticked any of the boxes in Section A, you will only qualify for a badge if the applicant: has a severe disability affecting both arms, drives regularly and finds it difficult to use all or some types of parking meters is over two years of age and is unable to walk or has considerable difficulty walking due to a permanent and substantial physical disability All applicants applying under the eligible subject to further assessment criteria may be requested to attend an independent mobility assessment. This is to ensure that these applicants meet the Department for Transport eligibility criteria. On receipt of the application form applicants will be contacted to arrange an assessment. If you are applying under the eligible subject to further assessment criteria please tick this box Fair Processing Notice to be issued to people who have submitted personal data to the council We are participating in an exercise to promote the proper spending of public money. We are required by law to protect the public funds we administer. We may share information provided to us with other bodies responsible for auditing or administering public funds in order to prevent and detect fraud. The Audit Commission currently requires us to participate in its anti-fraud initiative. For this initiative we are required to provide information we hold relating to blue badge holders so it can be compared to information provided to the Audit Commission by other participating public bodies. This increases our assurance that blue badges are being issued to the correct people and are being appropriately used. For further information on the Audit Commission s legal powers and the reasons why it matches particular information, see or contact them on: or or by public-enquiries@audit-commission.gov.uk Leeds City council are prosecuting misuse of blue badges You are applying for a blue badge for your own use. You can use this in any vehicle but you must be in the vehicle. Nobody else can use your blue badge, even if they are running an errand for you or have dropped you off. Misuse of blue badges is taken very seriously by Leeds City Council. You should be aware that your blue badge could be withdrawn if misuse is found.

4 Part C The applicants details Title (Mr, Mrs, Ms) Surname First name (s) Address Postcode: Contact Number Date of Birth NI Number Gender Male Female Town/City of Birth Country of Birth Surname at Birth Part D Your representative s details Do you give consent for your representative to contact us and discuss your application on your behalf? Yes No The name of your representative Their address if it is different to yours Contact number Their relationship to you If we have any queries, should we contact: Your representative You Can we contact your representative/ you by: Phone Post

5 Data protection All documents relating to this application will be dealt with in line with the Data Protection Act 1998 and may be shared within the local authority, with other local authorities, the police and parking enforcement officers to detect and prevent fraud. Any medical information that you have supplied to support this application is deemed, under the Data Protection Act, to be sensitive personal data and will only be disclosed to third parties as necessary for the operation and administration of the blue badge scheme, and to other government departments or agencies, to validate proof of entitlement or as otherwise required by law. If you are unable to sign, a representative can sign on your behalf and then complete Part D Signature Part E Photographs Please enclose a passport-style photograph taken in the last 6 months of the applicant. This should be a good quality image showing the applicant s head and shoulders preferably against a plain back ground Please print the applicant s name on the back and, if they are able, they should also sign. Part F If you are applying to Leeds City Council for the first time Please supply a photocopy of one confirmation of address and one confirmation of identity. Do not send original documents Confirmation of address Please supply a photocopy of one of the following as proof that you are a resident of Leeds: Utility bill Rent book/tenancy agreement Council Tax bill Whichever one you provide, it must contain a date within the last three months to show that you live in the Leeds area. Confirmation of identity You must attach a photocopy of one of the following as proof of your identity. The Department for Transport require local authorities to check individual identities to reduce fraud. If you are registered blind with Leeds City Council you do not need to supply this proof. If you are applying for a blue badge under the Eligible subject to further assessment - severe disability in both arms criteria then you must send a copy of your driving licence. Birth certificate / adoption certificate Driving licence Passport UK identity card Please send copies only as originals cannot be returned

6 Applicant s name. PLEASE PRINT YOUR FULL NAME Payment There is a fee for your blue badge, unless you qualify under the exempt criteria. Children under 16 do not need to pay. You can make this payment at any point during the application process if your application is unsuccessful this will be refunded. To make a payment please have your payment card details ready and call OFFICE USE ONLY Received Reviewed Awarded Awarded Refused Refused Pending Pending Fraud identified Payment received PROOFS AND PHOTOGRAPHS RECEIVED office use only Utility bill Rent book/tenancy agreement Council Tax bill Passport Birth certificate/adoption certificate Valid driving licence UK identity card CVI/BD8 Certificate DLA/PIP Letter Letter from Veteran s Agency Letter from MacMillan/Doctor Photos Cheque/PO/cash Old BB STFAX Prescriptions Information/Support Letters Please return completed applications to: Blue Badge, PO BOX 657, Leeds, LS1 9BS or to the address provided Date Stamp (office use only)