Claim form for Housing Benefit, Local Housing Allowance, Council Tax Reduction, free school meals and Distinctive School Uniform Grant

Transcription

1 Phoe: Text relay: (01656) Website: Bridged Couty Borough Coucil PO Box 107 Bridged CF31 1WB Name: Address: Referece umber: Date issued: / / Date of first cotact: / / Claim form for Housig Beefit, Local Housig Allowace, Coucil Tax Reductio, free school meals ad Distictive School Uiform Grat Please take the time to read these otes o the frot ad back of each page before you fill i this form. WHAT ARE HOUSING BENEFIT, LOCAL HOUSING ALLOWANCE AND COUNCIL TAX REDUCTION? Housig Beefit is help towards payig towards your ret if you ret your home from a housig associatio or do ot qualify for Local Housig Allowace (we will check this for you) Local Housig Allowace is a rate that we use to work out Housig Beefit for you whe you ret your home from a private ladlord Coucil Tax Reductio is help towards payig your coucil tax bill HOW TO FILL IN THIS FORM So we ca work out your beefit properly, we eed to kow about your circumstaces. We eed to kow what your icome is ad ay savigs you may have. If you have a parter, we eed details of their icome ad savigs too. We also eed to kow about other people who live with you ad, if you ret your home, how much ret you pay. Please aswer all the questios by tickig either Yes or No ad givig more details whe we ask. If you do ot aswer all the questios we will have to write to you to ask for the iformatio, which might delay your beefit. If there is ot eough room o the form for you to write everythig that you eed to, please write i the space i sectio 12 at the back of this form. It will help us if you make it clear which part of the form your iformatio is about. If you eed ay advice about claimig beefit or if you have ay problems fillig i the form or givig us proof, please call us o the phoe umber at the top of the page. You are also welcome to visit us at Civic Offices, Agel Street, Bridged for help. We ca also sed a housig officer to see you i your home. Use black ik to fill i this form ad sed it back to us as soo as you ca. Eve if you do ot have the proof we eed at the momet, sed this form back to us. If you wait, you could lose beefit. You ca sed us the proof or iformatio later, but please make sure you sed origial documets ad put your ame ad address o everythig that you sed. U010 10/13 1

2 WHICH PART OF THE FORM SHOULD I FILL IN? You must fill i all sectios of the form to claim Housig Beefit, Local Housig Allowace, Coucil Tax Reductio.However, if you are gettig Icome Support, icome-based Jobseeker s Allowace, icomerelated Employmet ad Support Allowace or Pesio Credit (Guarateed Credit) you oly eed to fill i sectios 1, 2A, 3, 4, 11, 12, 13 ad 14. If you have just applied for, or are waitig to hear back about ay of these beefits the you must fill i all sectios. WHAT PROOF MUST I GIVE? At the start of some sectios is a list of items that you ca provide as proof to support the iformatio you give us. These must be origial documets. If you do ot provide these documets at the same time as your form, you have oe moth to get them to us. The oe moth starts from the day we receive your form. We will try to sed your documets back to you withi two workig days of receivig them. If you do ot wat to post them to us you ca brig them to our Customer Service Cetre ad Civic Offices, Agel Street, Bridged, CF31 4WB. We are ope Moday to Friday 8am to 5:30pm, or you ca take them to oe of the iformatio poits below; Aberkefig Library Heol Llyfrau, Aberkefig, Bridged Maesteg Library North s Lae, Maesteg Pecoed Library Pe y Bot Road, Pecoed, Bridged Porthcawl Library Church Place, Porthcawl Pyle Life Cetre Helig Fa, Pyle, Bridged Ogmore Valley Life Cetre Pellwygwet, Ogmore Vale ABOUT SECTION 3 CHILDREN, FREE SCHOOL MEALS AND DISTINCTIVE SCHOOL UNIFORM GRANTS To get free school meals ad Distictive Uiform Grats from Year 7 owards, parets or guardias must be receivig oe of the followig: Icome Support Icome-based Jobseeker s Allowace Icome-related Employmet ad Support Allowace Pesio Credit (Guaratee Credit) Child Tax Credit (but ot Workig Tax Credit) with a icome of less tha 16,190 a year ABOUT SECTION 5 STUDENTS A studet is someoe who is o a course at a school, college or uiversity. If you are a part-time studet, you could get Housig Beefit, local Housig Allowace ad Coucil Tax Reductios. If you are a full-time studet you usually caot. Full-time meas that you atted lessos 16 hours a week. If you are a full-time studet, you could get beefit if you: Are receivig Icome Support or icome-base Jobseeker s Allowace; Are a sigle paret; Ad your parter are both studets ad are resposible for a child or childre; Are disabled; Are aged 60 or over; Are uder the age of 19 ad i further educatio (studyig A-Levels, BTEC or a similar qualificatio; Are resposible for a foster child; or.are receivig icome-related Employmet ad Support Allowace You could also get beefit if your parter is a studet but you are ot. The perso who is ot the studet must make the claim. If you are i ay doubt about whether or ot you qualify for these beefits, please cotact us before fillig i this form. ABOUT SECTION 10 ACCOUNTS, SAVINGS AND INVESTMENTS If you, your parter or both of you have savigs of 16,000 or over you will ot usually qualify for Housig Beefit, Local Housig Allowace or Coucil Tax Reductio. If you are i ay doubt about whether or ot you qualify for these beefits, please cotact us before fillig i this form. ABOUT SECTION 11 ABOUT R RENT I sectio 11 we ask you to tell us about ay services you receive that are icluded as part of your ret (service charges). Geerally we caot pay Housig Beefit or Local Housig Allowace for most services you receive, but we ca pay towards your service charges for thigs like heatig ad lightig i shared corridors. 2

3 Throughout the form we ask questios about you ad your parter. By parter we mea a husbad, wife or civil parter or someoe you live with as if they were your husbad, wife or civil parter. (A civil parter is someoe who has etered ito a formal agreemet (kow as a civil partership) with a same-sex parter so they have the same legal status as a married couple.) Title (Mr, Mrs, Ms, Miss) First ames Last ame Previous ame or ay other ame you are kow by SECTION 1 ABOUT Date of birth / / Age / / Age Natioal Isurace Number Daytime phoe umber address You do ot eed to tell us this, but it may speed up your claim if we eed to cotact you. Are you gettig Icome Support, icome-based Jobseeker s Allowace, Pesio Credit (Guaratee Credit) or icome-related Employmet ad Support Allowace? R HOME Do you ow your home or pay a mortgage for the house you live i? No Yes If Yes, are you a joit ower? No Yes If Yes, please write i the box who you joitly ow your home with No Yes No Yes Have you or your parter moved ito your home i the last 12 moths? No Go to the ext page Yes Please tell us about this below Whe did you move ito your curret / / / / address? If you have ot moved i yet, tell us whe you expect to move i. (ormally you will ot receive Housig Beefit or Local Housig Allowace util you move i) What was your or your parter s last address? If your parter lived at a differet previous address, please give us this address too. Did you ow the property? No Yes No Yes Did you ret the property? No Yes No Yes Did you claim Housig Beefit, Local Housig Allowace or Coucil Tax Reductio at your previous address? No Yes No Yes 3

4 R IDENTITY We eed to see proof of your ad your parter s idetity. You must show at least two of the items listed below to prove both your idetity ad your parter s idetity. Oe of these items must show your Natioal Isurace Number. If you do ot have a Natioal Isurace Number, please cotact us for advice. Our phoe umber ad address are o the frot of this form. Have you give us this iformatio before? Yes Go to Your Natioality below N0 Please fill i this sectio All documets you sed us must be origials. We caot accept photocopies Birth certificate Drivig licece Passport (it must be curret ad valid) Gas, water or electricity bill (that you have received i the last three moths) Bak statemets (that you have received i the last four weeks) Marriage certificate Letter of cofirmatio from a solicitor, a social worker, a probatio officer or from HM Reveue & Customs Medical Card Divorce or aulmet papers UK residece permit Home Office Stadard Ackowledgemet Letter (SAL1 or 2) You ca fid your Natioal Isurace Number o ay of the followig documets: P45 (give to you whe you leave a job) P60 (your yearly tax statemet if you are workig) Wage slips from your curret employer A letter from the Departmet of Work ad Pesios Natioal Isurace card (RD3) A letter from HM Reveue & Customs A State Pesio or Workig Tax Credit letter A Bak Statemet (if you are self-employed ad payig class 2 Natioal Isurace cotributios by direct debit) Which documet are you usig to cofirm your Natioal isurace Number? Which other documet are you providig to cofirm your idetity? R NATIONALITY Have you or your parter come to live i the Uited Kigdom, the Republic of Irelad, the Chael Islads or the Isle of Ma i the last two years? No Go to sectio 2 Please sed us your immigratio papers if you or your parter: Yes Please tell us about this here Have bee grated refugee status; Have bee grated exceptioal leave to remai or idefiite leave to remai ; or Are seekig asylum, or have bee grated asylum We eed to see these to work out whether or ot you or your parter are etitled to claim public fuds. We may cotact you i the future about this. We may also cotact the Home Office to check this iformatio. What is your atioality? What date did you last arrive i the UK? / / / / Are you seekig asylum i the UK? No Yes No Yes 4

5 The aswers you give to the followig questios will make sure that you get the right amout of beefit if you have a disability. You must provide proof of what disability beefits you get. All documets you sed us must be origials. We caot accept photocopies. PART A SECTION 2 AND S HEALTH Do you get Disability Livig Allowace / No Yes No Yes Persoal Idepedece paymet? If Yes, how much for care? How much for mobility? Do you get Attedace Allowace No Yes No Yes If Yes, how much? Do you get Costat Attedace Allowace/ No Yes No Yes Persoal Idepedece paymet? Have you claimed for ay of these beefits ad are waitig to hear about the outcome? No Yes No Yes If Yes, which beefit have you applied for? Are you registered blid? No Yes No Yes Have you bee registered blid i the last 28 weeks? No Yes No Yes Are you i hospital at the momet? No Yes No Yes Whe did you go i? / / / / Whe do you expect to come out? / / / / PART B Have you bee too ill to work for more tha 28 weeks? No Yes No Yes If Yes, please give the date you last worked. / / / / Do you get Mobility Supplemet paid with your War Disablemet Pesio? No Yes No Yes Have you bee give, or do you get a allowace for a ivalid carriage or ay other vehicle? No Yes No Yes Does ayoe receive Carer s Allowace for lookig after you? No Yes No Yes If yes, please tell us who gets the allowace What is their address? Have you claimed Carer s Allowace but have bee refused because you get aother beefit? No Yes No Yes If Yes, whe did you claim? / / / / Which beefit do you get istead? 5

6 SECTION 3 ABOUT R CHILDREN AND FREE SCHOOL MEALS Please give details about ay childre who live with you ad who you or your parter get Child Beefit for. If other childre live with you permaetly ad you or your parter do ot get Child Beefit for them, they should be icluded i sectio 4 o the ext page. Have you or your parter applied for, or are gettig Child Beefit? No Go to sectio 4 Yes Please tell us about this below You must sed proof that you receive Child Beefit for the childre who live with you. This ca be your award letter or a bak statemet (if Child Beefit is paid ito your bak or savigs accout) All documets you show us must be origials. We caot accept photocopies. First Names Last Name Date of birth Male or Female School Name / / / / / / / / / / If you do ot wat to receive free school meals please tick here If you do ot wat to receive a Distictive School Uiform Grat please tick here (comprehesive schools oly) Please read the otes o page 2 about free school meals ad Distictive School Uiform Grats Do ay of these childre get Disability Livig Allowace / No Yes Who? Persoal Idepedece paymet? Are ay of these childre registered blid? No Yes Who? Have ay of these childre bee registered blid i the last 28 weeks? No Yes Who? You may be able to get more beefit if you have a child who is looked after by a registered childmider or who goes to a ursery, playscheme or after-school club. Do you or your parter make paymets for childcare? No Go to sectio 4.Yes Please tell us about this below We eed to see five receipts for childcare if you pay weekly, or two if you pay mothly ad your cotract (if you have oe). If the amout you pay varies durig term time, holidays or because of your work patters, please give full details for a three-moth period ad sed us receipts. What is the ame ad address of your registered childmider or the ursery, playscheme or after-school club? What is their registratio or referece umber? This will be o your cotract. What is the ame of the child or childre beig cared for? How much do you sped each week o childcare? Does the amout you pay vary (for example, durig term time, holidays or because of your work patters)? No Yes 6

7 Other tha the people metioed i sectios 1 ad 3, does ayoe else live i your home? No Go to sectio 5 Yes Please tell us about this below Please fill i: Part A for people who are members of your family, or for people who live with you, but do pay ret (we call these o-depedets); ad Part B o the ext page for people who pay ret to live i your home, such as boarders, lodgers or teats. PART A NON-DEPENDENTS SECTION 4 OTHER PEOPLE LIVING IN R HOME You must sed us proof of icome for ayoe livig i your home. This ca be proof of the beefits they are gettig or up-to-date payslips (five if they are paid weekly or two if they are paid mothly). Or, if their employer could complete the eclosed cofirmatio of earigs form. If you caot sed proof, you may ot get all the beefit you are etitled to. If there are more tha three o-depedets livig i your home, give us their details i sectio 12. All documets you sed us must be origials. We caot accept photocopies. First ames Last ame Date of birth / / / / / / Relatioship to you (such as so, daughter, fried ad so o) PERSON ONE PERSON TWO PERSON THREE Do they get Icome Support, Pesio Credit (Guaratee Credit), icome-related Employmet & Support Allowace or icome-based Jobseeker s Allowace? No Yes No Yes No Yes Do they ormally work for more tha 16 hours or more a week? No Yes No Yes No Yes What are their earigs before tax ad Natioal Isurace are take off? Do they get ay other icome such as State Retiremet Pesio, Workig Tax Credit, Pesio Credit ad Support Allowace or other Pesio? No Yes No Yes No Yes If Yes, what do they get? How much are they receivig? Do they get iterest o their savigs? No Yes No Yes No Yes If Yes, how much do they get each year? Are they: A studet or a studet urse? I full-time educatio or a appretice? O youth traiig? I hospital? I priso or a place of detetio? A care worker? If yes, say which i the spaces here. (We may cotact you for more details) No Yes No Yes No Yes Do they have a severe learig disability, metal illess or a form of demetia? No Yes No Yes No Yes Are ay of the people you have metioed above married to each other or livig together as if they were married or livig together as civil parters? No Yes Tell us their ames. is the parter of 7

8 PART B BOARDERS, LODGERS OR TENANTS Do you share your home with boarders, lodgers or teats? No If Yes, please give us the followig iformatio: Yes Their full ame Their date of birth How much ret do you charge them? / / / / How ofte? Do you give them meals? No Yes Is a charge for heatig icluded i the ret? No Yes SECTION 5 STUDENTS Are you or your parter a studet? No Yes Please read the otes at the begiig of this form before fillig i this sectio. We eed to see the followig as proof of your icome. Your grat award or certificate for the curret academic year. Details of ay studet loas you have take out durig the curret academic year. Details of ay moey you receive from your parets or guardias. Please ask them to cofirm i writig how much they give you, how ofte ad how log the paymets will last. All documets you sed us must be origials. We caot accept photocopies. Are you a studet? No Yes No Yes Are you studyig: (Full time / Part time) Full Time Part Time Full Time Part Time What course are you followig (further educatio course, such as HND, BSc, MSc)? Whe does the curret academic year start? / / / / Whe does the curret academic year ed? / / / / How may years does the course cover? What is your curret year of study? 1st 2d 3rd 4th 1st 2d 3rd 4th Do you receive a studet grat? No Yes No Yes If Yes, how much? Are you receivig a studet loa durig this academic year? No Yes No Yes If Yes, how much? Do you receive sposorship (for example, from your employer)? No Yes No Yes If Yes, how much? Do you have a scholarship? No Yes No Yes If Yes, how much? Do you receive fiacial support from your parets or guardias? No Yes No Yes If Yes, how much? 8

9 Do you pay ito a private pesio scheme? No Go to sectio 7 Yes Please tell us about this below How much do you pay? How ofte (every week, every two weeks, every four weeks or every moth)? We will eed to see a letter from your pesio compay cofirmig your pesio scheme. We will also eed to see evidece of the amout you pay, such as a bak statemet. Are you or your parter workig (icludig volutary work), receivig Statutory Sick Pay, Statutory Materity Pay or Statutory Paterity Pay? No Go to sectio 8 Yes Please tell us about this below We eed to see proof of your ad your parter s earigs, Statutory Sick Pay, Statutory Materity Pay or Statutory Paterity Pay. We may cotact your employer to check the details you give us. Please sed us oe of the followig items: SECTION 6 PENSIONS SECTION 7 R EARNINGS Five of your most recet payslips if you are paid every week, three if you are paid every two weeks or two if you are paid every four weeks or every moth. We will oly accept prited payslips. A certificate of earigs form if you do ot have ay payslips or you get had-writte payslips A letter from your employer o headed paper (with your compay logo at the top of the letter) givig details of your expected earigs if you have just started a ew job. You will eed to sed payslips whe you receive them to cofirm your earigs. If you have told us that your wages are paid ito a accout, please remember to tell us about this accout i sectio 10. All documets you sed must be origials. We caot accept photocopies.evidece of the amout you pay, such as a bak statemet. WORKING FOR AN EMPLOYER Are you workig for a employer No Yes No Yes If yes who do you work for? What is the compay s address? Compay phoe umber What is your payroll umber (this will be o your payslip)? How may hours do you ormally work each week? How ofte are you paid (every week, every two weeks, every four weeks or every moth)? Whe did you start this job? / / / / How are you paid (by cheque, cash or ito your bak accout)? If your wages are paid ito a accout remember to tell us about it i sectio 10 How much are you paid? Whe will your ext pay rise be? / / / / Do you work regular overtime or get regular bouses, tips or commissio? No Yes No Yes If yes, how much do you get? 9

10 If this job is for a fixed time please tell us the date it will ed / / / / Do you get Statutory Sick Pay, Statutory Materity Pay No Yes No Yes or Statutory Paterity Pay? If Yes, how much? Whe did it start? / / / / Do you have more tha oe job? No Yes No Yes If Yes, what is the ame ad address of your secod employer? How may hours do you ormally work each week? How ofte are you paid (every week, every two weeks, every four weeks or every moth)? hours hours Whe did you start this job? / / / / How much are you paid (each week or moth)? If you or your parter have more tha two jobs, please give us details i sectio 12. SELF-EMPLOYED Are you or your parter self-employed? No Go to sectio 8 Yes Please tell us about this below We eed to see the followig origial documets as proof of your icome: Your latest accouts (icome ad expediture accout or tradig, profit ad loss accout ad balace sheet) Your busiess s bak statemets for the last three moths ad the origial letter from the Departmet for Work ad Pesios that gives details of ay govermet busiess allowace. If you have a busiess parter, the partership agreemet ad iformatio that cofirms the percetage of the busiess icome you receive. If you have started tradig i the last three moths, or if you do ot have ay accouts, please phoe us for advice. The umber is o the frot of this form. What kid of work do you do? What is your busiess called? What is your busiess address? Whe did your busiess start? / / / / How much do you ear each week? How may hours do you ormally work each week? Do you have a busiess parter? No Yes No Yes Do you have a govermet busiess allowace? No Yes No Yes Is this the oly work you do? No Yes No Yes (If No please tell us about this i sectio 12) 10

11 EMPLOYER S CONFIRMATION OF R EARNINGS Please fill i this sectio ad ask your employer to fill i the ext sectio, the sed it to the followig address. Bridged Couty Borough Coucil, P0 Box 107, Bridged, CF31 1WB Phoe: TO BE FILLED IN BY THE EMPLOYEE Name Natioal Isurace umber Address Date of birth / / Job title Sigature Payroll umber TO BE FILLED IN BY THE EMPLOYER Please help your employee by fillig i the iformatio we ask for below ad over the page. Earigs (before tax ad Natioal Isurace have bee take out) should iclude ay bouses, overtime, Statutory Sick Pay, Statutory Materity Pay, Statutory Paterity Pay, commissio ad so o. Please give this form back to your employee or sed it to the address above. How ofte does your employee get paid? How do you pay your employee? Every week Please give details of last five pay periods. Every two weeks Please give details of last three pay periods. Cash Every four weeks Please give details of last two pay periods. Cheque Every moth Please give details of last two pay periods. Direct bak trasfer Normal hours worked each week hours Tax code Please tur over EMPLOYER S CONFIRMATION OF R EARNINGS Please fill i this sectio ad ask your employer to fill i the ext sectio, the sed it to the followig address. Bridged Couty Borough Coucil, P0 Box 107, Bridged, CF31 1WB Phoe: TO BE FILLED IN BY THE EMPLOYEE Name Natioal Isurace umber Address Date of birth / / Job title Sigature Payroll umber TO BE FILLED IN BY THE EMPLOYER Please help your employee by fillig i the iformatio we ask for below ad over the page. Earigs (before tax ad Natioal Isurace have bee take out) should iclude ay bouses, overtime, Statutory Sick Pay, Statutory Materity Pay, Statutory Paterity Pay, commissio ad so o. Please give this form back to your employee or sed it to the address above. How ofte does your employee get paid? How do you pay your employee? Every week Please give details of last five pay periods. Every two weeks Please give details of last three pay periods. Cash Every four weeks Please give details of last two pay periods. Cheque Every moth Please give details of last two pay periods. Direct bak trasfer Normal hours worked each week hours Tax code Please tur over 11

12 Pay period edig Pay before tax ad atioal isurace Icome tax Natioal Isurace (NI) Tax Credits Pesio paymets Pay after tax ad Natioal Isurace Number of hours worked i this period Pay before tax ad Natioal Isurace so far for the curret year from: / / to: / / Pay (before tax ad Tax NI Pesio Net pay atioal isurace) Are these ormal earigs? No Yes If No, please explai here: Employer s ame ad address Phoe umber The iformatio I have give is true ad complete Employer s authorizatio stamp Your sigature Positio i your Date / / compay Pay period edig Pay before tax ad atioal isurace Icome tax Natioal Isurace (NI) Tax Credits Pesio paymets Pay after tax ad Natioal Isurace Number of hours worked i this period Pay before tax ad Natioal Isurace so far for the curret year from: / / to: / / Pay (before tax ad Tax NI Pesio Net pay atioal isurace) Are these ormal earigs? No Yes If No, please explai here: Employer s ame ad address Phoe umber The iformatio I have give is true ad complete Employer s authorizatio stamp Your sigature Positio i your Date / / compay 12

13 SECTION 8 BENEFIT INCOME Do you or your parter receive ay of the beefits listed below or are waitig to hear about a beefit that you have claimed for? No Go to sectio 9a Yes Please tell us about this below You must sed us up-to-date proof of all your beefits. This could be a letter showig how much you get, a up-todate paymet slip or a bak statemet showig the paymet beig made ito your accout. Please do ot sed it through the post. All documets you sed us must be origials. We caot accept photocopies. You must fill i all the boxes. Please write oe i the box if you do ot receive the beefit. BENEFITS RECEIVED Cotributio-based Jobseeker s Allowace HOW OFTEN DO GET THIS BENEFIT? Cotributio-based Employmet ad Support Allowace Icapacity Beefit Child Tax Credit Workig Tax Credit Pesio Credit (Savigs Credits) State Retiremet Pesio Uiversal Credit Have you or your parter chose to delay receivig your State Retiremet Pesio? No Yes We will write to you about this. Please tell us here about all the differet beefits, allowaces, pesios ad tax credits that you or your parter get or have applied for. This icludes thigs like: Severe Disablemet Allowace Carer s Allowace Materity Allowace Idustrial ijuries Disablemet Beefit Fosterig Allowace Widow s Pesio Bereavemet Allowace Widowed Mother s Allowace War Widow s Pesio ad War Disablemet Pesio Widowed Parets Allowace These are oly examples. It is ot a list of all the types of beefit icome you ca get. NAME OF BENEFIT HOW OFTEN DO GET THIS BENEFIT? BENEFITS CLAIMED Have you claimed a beefit that you are waitig to hear about? No Yes No Yes If Yes, which beefit have you applied for? Whe did you apply for the beefit? 13

14 Do you or your parter receive ay of the types of icome listed below? No 9B at the bottom of the page. SECTION 9A OTHER INCOME RECEIVE Yes Please tell us about this below Please provide proof of how much you get ad how ofte. If you are ot sure what proof you ca provide, please call the Beefits Sectio for advice. The phoe umber is o the frot of this form. You do ot eed to tell us about ay paymets you receive from the Eilee Trust, Idepedet Livig Fud, MacFarlae Trust or maiteace you receive for your childre from a ex-parter. All documets you sed us must be origials. We caot accept photocopies. You must fill i all boxes. Please write oe if somethig does ot apply to you or your parter. BENEFITS RECEIVED How much works, occupatioal or service pesio do you get? HOW OFTEN DO GET THIS INCOME? Whe was your last icrease? / / / / Who pays you this pesio? How much private or other pesio do you get? Whe was your last icrease? / / / / Who pays you this pesio? Are you over 60 ad have you chose to receive your works pesio at a future date? No Yes No Yes If you receive ay of the followig icomes, please tell us how much i the spaces provided: Pesio Protectio Fud Home icome pla Mortgage-protectio policy Coucillor allowaces Icome from property or lad you ow Icome from a trust fud Maiteace for yourself Loa-protectio policy Paymets istead of coal Charitable or volutary paymets such Ay other icome as paymets from frieds, family or charity Please say where this icome comes from ad how ofte you get it. NAME OF INCOME HOW OFTEN DO GET THIS INCOME? SECTION 9B PAYMENTS MAKE Do you or your parter pay towards a so or daughter goig to uiversity or college? No No Go to sectio 10 Yes We Will write to you about this 14

15 SECTION 10 ACCOUNTS, SAVINGS AND INVESTMENTS Please tell us below about ay accouts, cash savigs ad ivestmets you or your parter have. This icludes all bak, buildig society or post office accouts that you have, eve if the accouts are overdraw. We also eed to kow about ay savigs you have ivested i bods, savigs certificates, stocks, shares, uit trusts ad ay property or lad that you or your parter ow. Please tick No if somethig does ot apply to you or your parter. We eed proof of all your accouts, savigs ad ivestmets. We accept the followig: Bak, buildig society ad post office statemets or passbooks. These must cover at least the last two moths. We caot accept balace slips showig the curret amout. A letter from your bak or buildig society. This should show the type of accout held, the accout umber, the curret balace ad details of ay trasactios you have made i the last two moths. For ivestmets or other savigs (such as uit trusts ad savigs certificates) we eed to see documets that prove that you ow them. All documets you sed us must be origials. We caot accept photocopies. PART A Do you or your parter have ay accouts? No Yes These iclude curret, deposit ad savigs accouts with a bak, buildig society, post office accouts ad ay other accouts with a fiacial orgaisatio. If Yes, please tell us about them here. SORT CODE AND ACCOUNT NUMBER AMOUNT WHOSE ACCOUNT IS IT? Cash Savigs No Yes No Yes Premium Bods No Yes No Yes ISA, TESSA, No Yes No Yes PEP or TOISA 15

16 Do you or your parter have ay stocks, shares bods, uit trusts or Natioal Savigs Certificates? No No Go to part B below Yes Please tell us about them below. Stocks, shares, bods ad uit trusts Name of stocks, Name of compay shares, bods or trust uits Natioal Savigs Certificates Issue Number Number of uits PART B Have you bought paymets uder a auity No Yes No Yes (ivested a lump sum which pays you a regular icome)? Do you qualify for ay moey from a trust? No Yes No Yes Do you have ay busiess iterest which you have No Yes No Yes ot told us about o this form? If you have aswered Yes to ay of these questios, we will cotact you for more details. Do you have ay other kid of savigs or ivestmets? No Yes No Yes If Yes, how much is held? Please show us proof of this. Which bak or compay is this moey saved or ivested i? Do you or your parter ow ay other property or lad other tha the oe you are claimig for? No Go to sectio 11. This icludes properties i this coutry ad abroad Yes Please aswer these questios. What is the full address of the property or lad? Does ayoe else ow this property or lad with you or your parter? No Yes Give us their details i sectio 12. Is the property or lad up for sale? No Yes If Yes, whe did you put it o the market? / / Please show us proof of this. Do people live i the property? No Yes If the property is lived i, please give people s ames ad their relatioship to you (such as paret, ex-parter, teat ad so o). All documets you sed us must be origials. We caot accept photocopies. 16

17 SECTION 11 ABOUT R RENT We eed to see origial proof of the ret you have to pay. We accept your teacy agreemet or your ret book as proof. lf you do ot have either of these, please ask your ladlord or aget to fill i the eclosed proof of ret form. If your ret is registered with The Ret Service, we also eed to see your curret registratio documet. You must give us details of your ladlord ad aget (it you have oe). R TENANCY First ames Last ame Compay ame Address R LANDLORD R AGENT Phoe umber Whe did you start retig your home? Has your ret bee registered as a fair ret by the Valuatio Office Agecy No Yes (who used to be The Ret Service)? Do you have a shorthold teacy? No Yes How log is your teacy for? Six moths 12 moths other (please tell us) Does ayoe else share the ret with you ad your parter? No Yes If Yes, please tell us their ames. How much otice do you have to give to ed your teacy? How much is your ret? How ofte is your ret due? Every week Every two weeks Every four weeks Every moth Other (please tell us) What was the date of your last ret icrease? / / If you are behid with your ret, please tell us how may weeks you are behid. weeks Is ay part of your home used for busiess purposes? No Yes Is your home part of a shared-owership scheme (kow as New Build Home Buy)? No Yes Is your home a part of a co-owership scheme? (a co-owership scheme is oe where the teat is a member of the associatio No Yes that they ret a house from ad whe this eds will be etitled to a paymet related to the value of the house) Has ayoe who used to live with you died i the last 12 moths? No Yes 17

18 THE PROPERTY LIVE IN Is your home: a house? a flat? a room or rooms i a house? a bugalow? a bedsit? a maisoette? lf your house is t described by ay of the optios above, please say what type of home you live i here. Is your property: terraced? semi-detached? detached? How may floors does the whole buildig have? is your property let as: fully furished? partly furished? Not furished? How much of the furiture is provided by your ladlord? Noe Some Most All Is your ladlord resposible for decoratig the iside of your home? No Yes Does your home have cetral heatig? No Yes Do you have a garage? No Yes Does your home have a parkig area? No Yes If you ret a room, flat or bedsit, you must fill i this sectio, or your claim could be delayed. If you do t, skip this questio. Which floor is your home o? Secod floor First floor Groud floor Other (please tell us) Basemet If you are facig the frot of the buildig, is your home: at the frot? i the cetre? at the back? What is your room or bedsit umber? How may flats or bedsits are there i your buildig? Are you or your parter a Foster Carer? (We will write to you about this.) No Yes Do you or your parter eed a bedroom for a overight carer who does ot live permaetly at your address but stays regularly to provide care services? (We will write to you about this.) No Yes 18

19 Please tell us the umber of rooms i the property. Livig rooms Bedrooms Bedsits (oe roomed housig which combies sleepig ad livig area) Kitches Bathrooms Separate Toilets Other Rooms (such as a study or utility area) How may of these rooms are there i your property? How may are oly used by you ad your family? How may of these rooms do you share with other people (icludig other teats or your ladlord)? SERVICES Please tell us if ay of the followig services are icluded i your ret. lf you tick Yes, tell us how much you pay for each service. lf you do ot kow the exact cost of the service provided, we may use the most recet figures that the Departmet for Work ad Pesios set for these charges. Water rates No Yes Coucil tax No Yes Heatig No Yes Lightig No Yes Hot water No Yes Fuel for cookig No Yes Widow cleaig No Yes Cleaig iside the room or flat No Yes Cleaig, lightig or heatig shared areas No Yes Laudry equipmet (such as a washig machie) No Yes Laudry or bed lie that is washed for you No Yes Garage No Yes Emergecy-alarm system No Yes Cousellig ad support (which is help give to claim beefits, a budget ad debt cousellig) No Yes Nursig ad persoal care (which is help give to help you take your medicie, bathe or dress) No Yes Other service (please say what it is i the box provided) No Yes Breakfast No Yes Luch No Yes Eveig meal No Yes We may write to you to get more iformatio about these. 19

20 Are you retig your home from a housig associatio? No Please aswer the followig questios Yes Go to the ext page. Are you or your parter related to your ladlord, or your ladlord s parter or to your aget or your aget s parter (if you have a aget)? No Yes (who used to be The Ret Service)? Please say how you are related (such as ex-parter, paret, brother, brother-i-law, stepbrother ad so o). Are ay of your childre or your parter s childre related to your ladlord or ladlord s parter or to your aget or aget s parter(it you have a aget)? No Yes Who? What is their relatioship? (such as so, brother, father, mother, daughter) Has your ladlord ever lived i your property? No Yes Are you or your parter, a director of, or employed by the compay who are your ladlord? No Yes Is your ex-parter or your parter s ex-parter a director of, or employed by, the compay who are your ladlord? No Yes Is ay of your household a director of, or employed by, the compay who is your ladlord? No Yes Do you pay ret to a trust where either you or your parter are trustees (trustees look after property for the beefit of someoe else)? No Yes Do you pay ret to a trust where either your ex-parter or your parter s ex-parter is a trustee? No Yes Do you pay ret to a trust where ay member of your household (icludig childre) is a trustee? No Yes Have you or your parter ever owed all or owed part of the property you are retig? No Yes Do you have to ret your home as a coditio of your employmet? No Yes Are you livig i a property that is maitaied by a religious group (such as a church)? No Yes lf you have aswered Yes to ay of the questios above, please give us more details i sectio 12. We may cotact you for more iformatio about this. If you are uder 22 years of age, please aswer these questios. Have you ever bee i care (looked after by a local authority)? No Yes Have you ever bee give housig by Social Services? No Yes If you have aswered Yes to either of these questios, we may cotact you for more iformatio. 20

21 HOW WE WILL PAY Teats applyig for Local Housig Allowace (LHA) - we will pay Housig Beefit direct to you or your parter. lf you feel that this may cause a problem, please phoe us o Housig associatio ad teats that do ot qualify for LHA - we ca pay Housig Beefit to you, your parter or your ladlord s aget. If you get Housig Beefit or Local Housig Allowace ad you are havig moey problems, or you have problems that affect you payig your ret to your ladlord, the we may be able to help. Please cotact us o the umber above to tell us your problem ad we will try to help you or put you i cotact with a orgaisatio who ca help you. Do you wat us to pay: you? your ladlord (if you do t quality for LHA)? your parter? your ladlords aget (if you do t qualify for LHA) We ca pay Housig Beefit straight ito your or your parter s bak, buildig society or other accout (except Post Office card accouts). If you wat us to pay you i this way the please fill i the sectio below. We pay every two weeks or mothly for the previous two weeks or moth. If you do ot give us your bak details, we will pay you by cheque. If you have asked us to make the paymet out to you, you will eed a bak accout i your ame so you ca cash the cheque. If you do ot have a bak accout ad would like to ope oe, we ca give you advice o how to ope oe. Please phoe us o Name the accout is i Name of bak or buildig society Brach address Sort Code Accout umber - - Buildig society roll umber SHARING INFORMATION Sharig iformatio with your ladlord could help us deal with your claim more quickly. We may eed to ask them for details about your claim, such as whe your teacy bega or they may ask us about the progress of your claim. We will ot give your ladlord ay iformatio regardig your persoal or fiacial circumstaces(e.g. what type of icome you get or your date of birth or Natioal Isurace umber) Ca we share iformatio about your claim (icludig the progress of your claim) with your ladlord or aget? No Yes If Yes, please sig here. You ca withdraw your permissio allowig us to discuss your claim with your ladlord at ay time. 21

22 BACKDATING BENEFIT CLAIMS We ormally pay beefit from the Moday after we receive your claim. Sometimes we ca pay from a earlier date if you have good reasos why you have ot claimed earlier. If you wat us to cosider payig your beefit from a earlier date, please give as much detail as you ca i the space below. Tell us the date you wat to claim from. / / Please tell us why you did ot claim earlier. CHECKLIST Please check that you have aswered all the questios that apply to you, fill i sectio 13 ad remember to sig the form i sectio 14. If you do ot have the proof we eed at the momet, sed the form back to us ayway. We will the write to you to cofirm the date we received your claim ad we will ask you for the iformatio ad proof that we eed. The letter we sed you will iclude your claim form. You should sed this back to us with all the details we eed. We will ot be able to pay you beefit util we have all the proof we eed. Please tick the boxes below to tell us what you are sedig with this form. Have you aswered all the questios? Yes Yes Have you siged the form? Yes Yes Have you give us: proof of your idetity ad Natioal Isurace umber? Yes Yes proof of your ret? No Yes proof of all your icome? Yes Yes proof of all your accouts ad savigs? Yes Yes proof of icome for ayoe else livig i your home if this applies)? Yes Yes a certificate of earigs? Yes Yes Remember, if you do ot provide all the iformatio we have asked for o this form, we might ot be able to pay you ay beefit. Please use this space to tell us about aythig else you thik might help your claim. 22

23 SECTION 13 EQUAL OPPORTUNITIES We eed to check the ethic group of everyoe who applies for beefit to make sure that we are meetig your eeds. It would be helpful if you could fill i the followig form, but you do t have to. What is your ethic group? (Please tick the box that applies to you.) A: WHITE British Eglish Irish Welsh Scottish B: ASIAN OR ASIAN BRITISH Idia Pakistai Bagladeshi Ay other Asia backgroud C: MIXED White ad Asia White ad black Africa White ad Caribbea Ay other mixed backgroud D: BLACK OR BLACK BRITISH Caribbea Africa Ay other black backgroud E: CHINESE OR OTHER ASIAN ETHNIC GROUP Chiese Japaese Ay other Asia ethic backgroud F: OTHER ETHNIC GROUP Other (Please tell us) USEFUL CONTACTS Bridged Citize s Advice Bureau Groud Floor 26 Durave Pl, Tow Cetre, Bridged CF31 1JD Phoe: Website: Maesteg Citizes Advice Bureau Coucil Offices Talbot St, Maesteg CF34 9BY Phoe: Website: Shelter Cymru 25 Walter Road Swasea SA1 5NN Phoe: Website: Age Cocer PO Box 243 Bridged CF31 9BY Phoe: Website: Pesio Service PO Box 139 Swasea SA6 8WD Phoe: Website: Bridged Credit Uio Lifelog Learig Cetre Merfield Close Sar CF32 9SW Phoe: Website 23

24 SECTION 14 DECLARATION IF ARE FILLING IN THIS FORM FOR SOMEONE ELSE Please tell us why you are fillig i this form for someoe else. l cofirm that l have read each questio to the perso claimig ad l have accurately writte the aswers they gave me. Name of the perso who filled i the form Sigature of the perso Relatioship to the perso claimig (such as mother, so or careworker) PLEASE READ THIS DECLARATION CAREFULLY BEFORE SIGN AND DATE IT: l uderstad that if I give iformatio that is ot correct or complete, you may take legal actio agaist me. l uderstad that you will use the iformatio l have give to process my claim for Housig Beefit, Local Housig Allowace, Coucil Tax Reductio, free school meals ad a Distictive School Uiform Grat. You ca check some of the iformatio with other departmets withi Bridged Couty Borough Coucil ad with other coucils. You may use ay iformatio I have give o this form ad ay other claim for beefits that I have made or may make. You may give some iformatio to other coucil departmets ad govermet orgaisatios as allowed by law. I kow l must let the Housig Beefit sectio of the coucil kow immediately i writig about ay chages i my circumstaces which might affect my claim. I declare that the iformatio l have give o this form is correct ad complete. Your sigature Date / / Your parter s sigature Date / / REMEMBER, IF MAKE A FALSE STATEMENT OR WITHHOLD INFORMATION MAY BE PROSECUTED. HOW WE COLLECT AND USE INFORMATION We will use the iformatio we collect, both o this form ad from supportig evidece you give us, to process your claim for Housig Beefit, Local Housig Allowace, Coucil Tax Reductio, free school meals ad a Distictive School Uiform Grat. Oce we collect your iformatio we may share it with other coucil departmets to help provide a complete service to you. We may check iformatio you (or ayoe else) have provided with other iformatio we hold. We may also get iformatio from other orgaisatios, or give iformatio to them:- to check that the iformatio you have give is accurate; to prevet or detect crime; to protect public fuds i other ways; ad for reasos allowed or required by law. We will use your iformatio i lie with the Data Protectio Act We (Bridged Couty Borough Coucil) are the data cotroller for the purposes of the Data Protectio Act