Important Information. At the start of each part in the form, it will tell you whether you need to complete that part or not.

Transcription

1 Claim Form for Housing Benefit Council Tax Reduction Free School Meals Name: Address: For official use only Date of first contact: Date of issue: Issued by: Claim Ref: Date received and Office stamp : Use this form to claim help with any or all of the following: Your Rent Your Council Tax And where applicable School Meals Housing Benefit provides financial assistance to people on a low income pay their rent. Council Tax Reduction reduces the amount of Council Tax people on low income pay. Free School Meals provides your child or children with a meal whilst at school. We automatically use the information on this form to work out if you can get free school meals. We will write and tell you if you are entitled to help. If you do not want your information used in this way you can tell us later in the form. Don t Use this form : If you are already getting Housing Benefit, Council Tax Reduction and/or Free School Meals from us and you are changing your address within Powys. Use our shorter Change in Address form instead. You can get this form from us. If you want to claim free school meals only. A shorter claim form is available from the school, any Powys Council customer service point or download from Return your completed form to us straight away, otherwise you might lose money. If you cannot get the evidence we need at the moment, please send the form to us now and send the evidence later. If you are having difficulty getting the evidence then please let us know as we may be able to help you. If you need a copy of this form in Welsh please contact us. Important Information At the start of each part in the form, it will tell you whether you need to complete that part or not. Please read all the notes below carefully before you fill in this form 1

2 How to fill in this form The form may look rather long, but we have to ask a lot of questions to make sure we pay the correct amount of Housing Benefit, Council Tax Reduction and/or Free School Meals to the right person. You may not have to fill in all parts of the form, but you must fill in any part that is relevant to you. Please use a black pen to complete your form. If you make a mistake, just cross it out and put the right answer next to it. If you do not answer all the questions, we will either send the form back or write to you for the information, and this will delay your claim. If there is not enough room on the form for you to write everything that you need to, use the space in Part 10 at the back of the form. It will help us if you make it clear which part of the form your information is about. If you need help filling in this form please contact us. We can give you help over the phone or you can call or make an appointment at one of our offices shown below, or you can get in touch with an independent organisation like Powys Citizens Advice Bureau. You can find their address in your local telephone directory or call or visit their website: Evidence we need to see evidence of some of the things you tell us about. There is a checklist on the back page of this form to help you. If you are not sure if we need to see supporting evidence, please contact us. We will tell you what we need to see. We cannot pay you benefit until we have all the evidence we have asked for. When we usually pay Housing Benefit and/or Council Tax Reduction from: If you move into a new home and claim Housing Benefit and/or Council Tax Reduction in the same week, your claim will normally start from the day you moved in. If you make a claim for Housing Benefit in a different week to when you moved in your Housing Benefit will normally start from the Monday after we receive your claim form. Your Council Tax Reduction will normally start on the day we received your claim form. If this is a repeat claim and you get your form to us within one calendar month from when your last claim ended, we will pay your benefit from the day after the last claim ended. If the form arrives more than one calendar month after your last claim ended, we will usually only be able to pay your Housing Benefit from the Monday after the date we received your claim form, and your Council Tax Reduction will normally start from the day we received your claim form. Backdating a Housing Benefit and/or Council Tax Reduction Claim You can ask us to backdate your claim if you want to claim benefit from an earlier date and you have a good reason for not claiming benefit earlier than you did. You must fill in Part 10 and, give us as much information as possible if you want us to backdate your claim. What to do next This is our designated office (our official address) for you to post claims, or details of changes in your circumstances that may affect your benefit. Or you can bring the form and evidence to us at any one of the designated offices shown below. All original supporting documents will be photocopied free of charge. When you have filled in the form, sign it and send it to us at: Powys County Council, PO Box 71, Llandrindod Wells, Powys, LD1 9AQ. Customer Service Points (at our main offices) Neuadd Brycheiniog Cambrian Way Brecon Powys LD3 7HR The Gwalia Ithon Road Llandrindod Wells Powys LD1 6AA 2 Neuadd Maldwyn Severn Road Welshpool Powys SY21 7AS Opening hours: Monday to Thursday 9.00am to 5.00pm, and Friday 9.00am to 4.30pm Other Customer Service Points Customer Services Point Back Lane Newtown, Powys Customer Services Point Leisure Centre Rhayader, Powys Customer Services Point Canolafan Hyddgen Machynlleth, Powys The opening hours vary. Please contact us to check or visit our website:

3 Other designated offices (in the following towns) Builth Wells Library+ Knighton Library + Presteigne Library + Crickhowell Library + Llanidloes Library + Ystradgynlais Library + Hay-on-Wye Library + Llanfyllin Library + The opening hours vary. Please contact us to check or visit our website: At Library + only valuable documents such as passports, driving licences and certificates will be photocopied and you will be provided with a pre-paid envelope to send your form & other supporting documentation to us. Contact details You can phone us on and on You can us at benefits@powys.gov.uk You can write to us at Powys County Council, PO Box 71, Llandrindod Wells, Powys, LD1 9AQ You can call in to see us at any one of our Customer Service/reception points. If you need help to complete your form and/or have your documents checked please ring us to make an appointment to see a customer service benefits advisor. Changes in circumstances you must tell us about You must tell us immediately in writing about any change in your circumstance and provide evidence of the change. You must write to us at Powys County Council, PO Box 71, Llandrindod Wells, Powys, LD1 9AQ. It is not good enough just to tell Jobcentre Plus or The Pension Service about changes. You must write to us and tell us as well. If you delay telling us about a change in your circumstances, we may pay you too much benefit and you will have to pay this back. You may also lose out on benefit you would have been entitled to. Examples of the types of changes you must tell us about straight away If your entitlement to Income Support, Jobseeker s Allowance, Employment and Support Allowance or Pension Credit starts or ends. If there is any change in the type or amount of income that you or a member of your household receives. If there is any change in your or your partner s savings, or investments. If the household members change, for example: a partner comes to live with you; someone leaves or joins the household; or a child is born or leaves school. If the amount of rent you pay changes. How we pay Housing Benefit, Council Tax Reduction and Free School Meals if you qualify Housing Benefit If you are a council tenant, housing benefit is awarded as a rebate (i.e. credit) to your rent account so you will have less to pay. If you are a private tenant or housing association tenant, housing benefit is awarded as an allowance (i.e. a payment) either to your landlord or yourself. Council Tax Reduction Is awarded as a rebate (i.e. credit) to your Council Tax account so you will have less to pay. Free School Meals We will tell your child s school. 3

4 Part 1 About you and your partner You need to complete this part for help with Rent, Council Tax and School Meals Do you have a partner who normally lives with you? Just answer the questions about You. By partner we mean someone you are married to or live If you have a partner, you must answer all with as if you were married to them, or a civil partner or a questions about them as well as yourself. person you live with as if you were a civil partner. A civil partner is someone who has entered into a formal agreement (known as a civil partnership ) with a same sex partner so they have the same legal status as a married couple. Last name: First names: Any other names you have used Title (Mr, Mrs, Ms and so on): You Your partner Date of birth: National Insurance number: You can find this on payslips or letters from Social Security or the Tax Office If you do not have a National Insurance number or cannot find it, tick this box Address you are claiming benefit for including the room number if you have one. Do not tell us your partner s address if it is the same as yours. : : What date did you move to this address? If you have not moved in, when do you expect to move in? Your daytime phone number Your mobile number Your address Please note that providing us with your mobile number and/or address means we will use these to contact you, if necessary. Have you or your partner claimed Housing Benefit or Council Tax Reduction before? Please tell us below Please tell us below What date did you last claim? Which council did you claim from? What name did you use for the claim? What address did you claim for? : : 4

5 Part 1 About you and your partner (continued) You Your partner If you or your partner have moved home in the last 12 months, tell us your last address if it is different from above. Tell us if you where the homeowner, a private tenant, a council tenant or a lodger at this address. Have you or your partner come to live In England, rthern Ireland, Scotland, Wales, the Republic of Ireland, the We will write to you about this Channel Islands or the Isle of Man in the last two years? We will write to you about this What is your nationality? If your nationality is not British, on what date did you last enter the UK? The UK is England, rthern Ireland, Scotland and Wales. Are you or your partner in hospital at the moment? Please tell us about it Please tell us about it below below When did you go in? When will you come out, if you know this? Please tick if you or your partner are: in legal custody severely mentally disabled registered blind long-term sick or disabled Are you or your partner aged 16 or 17 years of age and recently left local authority care? We will contact you if we need any more information 5

6 Part 2 About dependent children and young people who live with you You need to complete this part for help with Rent, Council Tax and School Meals We need to know about any children or young people in your household who you are responsible for and who are: a) under 16;or b) aged 16 or 17 and registered for work or youth training; or c) aged 16, 17, 18 or 19 and in education doing a course not higher than GCE A Level, NVQ level 3 or BTEC National Diploma that they started before they were 19; or d) aged 16, 17, 18 or 19 and in training on the Entry to employment programme or Programme-led pathways into apprenticeships that they started before they were 19. Are you responsible for any children or young people who live with you? Go to Part 3 Please fill in their details below Full name Relationship to you or your partner Date of birth Tick if you get Child Benefit for them Name of school or college Tick if they are registered blind Do you get Disability Living Allowance or Personal Independence Payment for them? Please give us your Child Benefit number. This is on your award letter from the Child Benefit Office. Numbers Letters If you don t want free school meals for your child or children, even if you qualify for them, you can tell us this in Part 11 (About how we collect and use information). 6

7 Part 3 About other people who live in your home You need to complete this part for help with Rent and Council Tax Do any adults usually live with you and your partner? By adults we mean people aged 16 and over and you do not receive Child Benefit for them. Go to Part 4 Fill in this section. If you need more space, use Part 10 Person 1 Person 2 Person 3 Person 4 Full Name Relationship to you or your partner Date of birth National Insurance number Are they: full-time student? or or or or a student nurse? or or or or If, please send evidence (for example, their student certificate). on youth training (work-based or or or or training for young people)? an apprentice? or or or or a carer? (we may write to you or or or or for more details) severely mentally disabled? or or or or registered blind? or or or or on Income Support? or or or or on income-based Jobseeker s or or or or Allowance? on income-related Employment or or or or and Support Allowance? on Pension Credit? or or or or receiving Attendance Allowance, or or or or Disability Living Allowance or Personal Independence Allowance? If, say how much a week 7

8 Part 3 About other people who live in your home (continued) Are they in hospital at the moment? Person 1 Person 2 Person 3 Person 4 or If yes, when did they go in? or If yes, when did they go in? or If yes, when did they go in? or If yes, when did they go in? When will they come out (if known)? When will they come out (if known)? When will they come out (if known)? When will they come out (if known)? Are they in legal custody (serving a prison sentence or remand?) or If yes, when did they go in? or If yes, when did they go in? or If yes, when did they go in? or If yes, when did they go in? When will they come out (if known)? When will they come out (if known)? When will they come out (if known)? When will they come out (if known)? Do they normally work for more than 16 hours or more a week? or If, how much do they earn before any deductions? or If, how much do they earn before any deductions? or If, how much do they earn before any deductions? or If, how much do they earn before any deductions? We need to see evidence (e.g. their last pay slip) of how much they earn Do they have any other income? Make sure you tell us about all other income they have i.e. any benefits or allowances you have not told us about on this form, and interest from savings & investments. or or or or If, please send evidence (e.g. their last bank statement, pension advice slip or benefit award letter) Do they pay you or your partner money for rent or board and lodging? or If, how much? or If, how much? or If, how much? or If, how much? Does this include money for food? Does this include money for food? Does this include money for food? Does this include money for food? or or or or Are they a joint tenant with you? Are they a joint owner or buying your home with you? Are any of the people who normally live with you civil partners or married to each other or living together as if they are married? or or or or or or or or or or or or If, tell us their names below is the partner of is the partner of 8

9 Part 4A About you and your partner working for an employer You need to complete this part for help with Rent, Council Tax and School Meals Do you or your partner work for an employer? Go to Part 4B (about self-employment) Answer all the questions in this part. You Your partner What kind of work do you do? What is your employer s name and address? What date did you start this job? What is your payroll, employee or staff number? Are you employed for a limited period When do you finish? How often do you get paid? Every Every When do you finish? How much is your gross pay? What are the deductions? Income Tax National Insurance Other How are you paid? (for example, in cash, cheque or into a bank account?) Income Tax National Insurance Other When was your last pay rise? When will your next pay rise be? How many hours a week do you usually work? Are you getting Statutory Sick Pay (SSP), Statutory Paternity Pay (SPP), adoption Pay or Statutory Maternity Pay (SMP) from your employer at the moment? From what date? From what date? Are you getting any other sick pay or maternity pay from your employer at the moment? Do you pay into a private or company pension scheme? How much and how often? Every 9 How much and how often? Every

10 Part 4B About you and your partner s self-employment You need to complete this part for help with Rent, Council Tax and School Meals Are you or your partner self-employed? Go to Part 4C (About any other work) Answer all the questions in this part. You Your partner What kind of work do you do? When did the business start? What is the business address? Do you have any business partners? If you have more than one, tell us their name and address in Part 10 Tell us their name and address Tell us their name and address How many hours a week do you usually work? Do you get a Business Start-up allowance? Do you pay into a private pension scheme? How much and how often? Every Every How much and how often? Every Every How much and how often? How much and how often? Part 4C About any other work you and your partner have You need to complete this part for help with Rent, Council Tax and School Meals Do you or your partner do any other work? This could be a second job for another employer, voluntary work even if you don t get paid for it. Go to Part 5A (Employment and Support Allowance, Income Support, Jobseekers Allowance & Pension Credit) Answer all the questions in this part. You Your partner What other work do you do? 10

11 Part 4C About any other work you and your partner have (continued) You Your partner What is the name and address of the person you do this work for? When did you start this work? How many hours a week do you usually work? Do you get paid? If you only get expenses or tips, still tick and give details Tell us about it below Tell us about it below How much do you get before deductions? How often do you get paid? Part 5A About you & your partner s Employment and Support Allowance, Income Support, Jobseeker s Allowance & Pension Credit You need to complete this part for help with Rent, Council Tax and School Meals Are you or your partner getting or waiting to hear about a claim for:- Employment & Support Allowance Income-related; Income Support, Income-based Jobseekers Allowance; or Guaranteed Pension Credit? Go to Part 5B (Allowances, benefits, credits & pensions) Answer all the questions in this part. Tell us which benefits you or your partner are getting You Your partner Employment and Support Allowance Income Related Date started Date started Income Support Date started Date started Income based Jobseekers Allowance Date started Date started Pension Credit (guarantee credit) Date started Date started Tell us which benefits you or your partner are waiting to hear about Employment and Support Allowance Income Related Date applied Date applied Income Support Date applied Date applied Income based Jobseekers Allowance Date applied Date applied Pension Credit (guarantee credit) Date applied Date applied 11

12 Part 5B About you and your partner s other allowances, benefits, credits and pensions You need to complete this part for help with Rent, Council Tax and School Meals Are you or your partner getting any allowances, benefits, credits or pensions listed below, or are you waiting to hear about any that you have applied for? Tell us about the full rate before any deductions You Go to Part 5C (About any other income you have) Tell us below. Adoption Allowance Attendance Allowance Bereavement Allowance Carer s Allowance Child Benefit Child Tax Credit Disability Living Allowance Care Disability Living Allowance Mobility Your partner Tell us how often you get it or if you are still waiting Is any of the DLA paid to the mobility fund? Employment Support Allowance (Contribution based) Fostering Allowance Guardian s Allowance Jobseeker s Allowance (Contribution-based) Incapacity Benefit Industrial Death Benefit Industrial Injuries Disablement Benefit Maternity Allowance Pension Credit (Savings Credit) Personal Independence Payment - Standard Personal Independence Payment - Enhanced Severe Disablement Allowance Widowed Mother s Allowance State Retirement Pension War Disablement Pension War Widow s Pension Widowed Parent s Allowance Widow s Pension Working Tax Credit Youth or Government Training Allowance 12

13 Part 5B About you and your partner s other allowances, benefits, credits and pensions (continued) Any other benefit not listed here What benefit is it? You Your partner Tell us how often you get it or if you are still waiting Does anyone get Carer s Allowance for looking after you or your partner? Have you or your partner been told that you are entitled to Carer s Allowance even if you do not receive it, because you are getting another benefit instead? 13

14 Part 5C About any other income you and your partner have You need to complete this part for help with Rent, Council Tax Do you or your partner receive any of these types of income, or have you applied for any of them? Go to Part 6 (About Capital) Tell us below You must tell us about all your income. You do not need to tell us about payments from the Eileen Trust, the Independent Living Fund or the McFarlane Trust. You Work, occupational or service pension Your partner - when was the last increase? - who pays you this pension Tell us how often it is received Any other pension - when was the last increase? - who pays you this pension Payments from a Financial Assistance Scheme due to loss of occupational pension Are you over 60 and have chosen to receive your work pension at a later date? Apprenticeship Board and lodgings income Career development loan Charitable or voluntary payments Councillor allowances Home income plan or annuity Income from land or property Income from a trust fund Loan Protection policy Maintenance paid for your child/ren Maintenance paid for you Mortgage Protection policy Payments instead of coal Student loan or grant Sub-tenant(s) income Part-time fire-fighter, auxiliary coastguard, territorial army or reserve forces funding. Any other income not listed here What benefit is it? 14

15 Part 6 About you and your partner s Capital (i.e. bank accounts, savings, investments and property) You need to complete this part for help with Rent, Council Tax Do you or your partner have any accounts in banks, building societies or the post office (including current accounts, basic bank accounts, post office card accounts and Girobank accounts)? Give the account name, number and amount in each account. Account Name Account Number Premium Bonds Total amount Unit trusts, ISAs, PEPs, TESSAs,TOISAs or other investments How many accounts? Total amount Income bonds or capital bonds How many accounts? Total amount Money or property held in trust Any other savings or investments? How many accounts? How many accounts? Total amount Total amount Any other type of savings or investment Shares - approximate value Name of company the shares are held in Number of shares held Shares - approximate value Do you or your partner have any National Savings Certificates? Do any of your or your partner s savings or investments include: money from the sale of a house, or money from a charity? Apart from your home, do you or your partner own any other property or land in this country or abroad? 15

16 Part 6 About you and your partner s Capital (i.e. bank accounts, savings, investments and property) continued About the property or land that you own What is the full address of the property or land? Is the property up for sale? If it is up for sale, when did you put it on the market for sale? What is its current value? Is the property or land mortgaged? If, how much do you owe on the mortgage? How much are your monthly mortgage payments? Does anyone live in the property? If, tell us: who lives there; and how they are related to you, for example are they your parent, ex-partner or tenant? Have you or your partner received: a Far Eastern Prisoner of War Compensation payment; or a compensation payment made to victims of atrocities that happened during the Second World War? We need to know this to make sure we do not count it as part of your savings. What payment did you receive? Who received the payment? a Far Eastern Prisoner of War Compensation payment; You Your Partner a compensation payment made to victims of atrocities that You Your Partner happened during the Second World War Have you, your partner or any children you are claiming for received a payment for the vcjd (Creutzfeldt- Jakob Disease) Trust? We will write to you about it. Have you or your partner received a Personal Injury Sum payment within the last 52 weeks? How much did you or your partner receive? When did you receive it? 16

17 Part 7 About you and your partner s expenditure You need to complete this part for help with Rent, Council Tax Do you or your partner pay a registered childminder, nursery or after-school club childminding costs for any dependent child/ children? If yes tell us Child s name First Child Second Child Third Child Name and registration number of the minder How much do you pay a week? Do you or your partner pay into a personal (private) pension scheme or stakeholder pension scheme? If yes tell us How much do you pay and how often? Do you or your partner pay toward any student s cost? For example, for your son, daughter, step-son or daughter. If yes tell us: How much do you pay and how often? You Your partner every every every every Part 8A About where you live You need to complete this part for help with Rent. Please tick what type of property you live in: Detached house Flat in a house Board and lodgings Semi-detached house Flat in a block Hotel Terraced house Flat over a shop Residential nursing home Maisonette Bedsit, rooms or studio flat Residential care home Bungalow Hostel Semi-detached bungalow Other give details Caravan, mobile room or houseboat 17

18 Part 8A About where you live (continued) How many floors are there in the building you live in? If you live in a flat, bedsit, rooms or part of a house, which floor or floors do you live on? Which part of that floor or floors do you live on (for example all, back or front)? How many rooms are there in the building? In the whole building Just for you and your household That you share with other households Bedsitting rooms Living rooms Bedrooms Bathrooms or shower rooms Toilets Kitchens Other rooms Do you or your partner regularly receive overnight care from a carer or carers who do not live in your home? If how often does a carer stay overnight Who receives this care? (We may write to you about this) Do you have a main home somewhere else? If your main home is somewhere else in the UK or abroad, tick, even if you do not pay rent for it. What is the address? You Your Partner Both Do you pay rent for this home? If, how much do you pay and how often? Have you or your partner ever owned the home you are now renting? every If what date did you sell it? Why did you sell it? 18

19 Part 8B About your rent and landlord You need to complete this part for help with Rent. Do you pay rent to Powys County Council? What is your landlord s full name, contact phone number and business address? By landlord we mean the person or organisation who owns the property you live in. Continue with the questions here Go to Part 10 Landlord's contact phone number Landlord s address (if know) If your landlord has an agent, tell us the agent s contact phone number their full name and address. By agent we mean the person or organisation you actually pay your rent to Agent s contact phone number Agents address (if know) These next questions are about your landlord. If you answer, to any of them, give details in the space below. Has your landlord ever lived in the property you are renting? Is your landlord, or your landlord s agent, related to you, your partner, your children or your partner s children? Related means related by marriage even if the marriage has ended. Examples of being related include ex-wife, aunt, brother, sister, father, grandson, grandmother, son-in-law or step-daughter. Is your landlord, or your landlord s agent, your ex-partner or your partner s ex-partner? Are you or your partner working for, or a director of, the company which is your landlord? Is your ex-partner, or your partner s ex-partner, working for, or a director of, the company which is your landlord? Is anyone in your household working for, or a director of, the company which is your landlord? Do you pay rent to a trust where either you or your partner is a trustee? Do you pay rent to a trust where either your ex-partner or your partner s ex-partner is a trustee? Do you pay rent to a trust where any member of your household is a trustee? Give details here if you answered '' to any of the questions above: 19

20 Part 8B About your rent and landlord (continued) When did you start renting your home? When did you move to this address? If you have not moved in yet, tell us when you expect to move in and then tell us when you have actually moved in What sort of tenancy do you have? For example, assured, short hold, licensed, regulated, tied or something like this. How long is the tenancy for? What is the property let as? Tick the box that applies. How much is the rent for your home and how often? For example, every week, every two weeks, every four weeks or every month. Furnished Hardly any furniture every Partly furnished? Unfurnished Does anyone else share the rent with you and your partner? Tell us the details below. Tell us their names and their relationship to you and your partner. How much of the rent do they pay and how often? For example, every two weeks, every four weeks or every month. every Has your rent changed in the last 12 months? Send us evidence of the date it changed and by how much When is the next rent increase due? Could you afford to pay the full rent when you moved in? Have you received Housing Benefit in the last 52 weeks? Has anyone who normally lived with you died in the last 52 weeks? You may be entitled to more Housing Benefit. Tell us who When did they die? How were they related to you? Has the rent been registered as a fair rent by a rent officer? Please send us the notice of registration (RO5). Do you have any weeks when you do not have to pay rent? How many in a year? Are you behind with your rent? By how many weeks? How much do you owe? Is the property you are renting maintained by a religious order? What is the Religious order? 20

21 Part 8B About your rent and landlord (continued) Who has to pay the Council Tax bill for your home? You Your Partner Someone else Tell us who How is the water-supply provided to the property? Private supply Mains supply You Your landlord Does the rent include money for meals/food How much? every For which meals? Breakfast Lunch Evening Meal Does the rent include money for the following? Heating How much? Lighting How much? Hot water How much? Fuel for cooking How much? Laundry How much? Cleaning rooms or windows How much? Gardening How much? Garage or parking space How much? Personal care and support How much? Do you pay any service charges separate from your rent? For example, for cleaning or lighting in shared areas, an alarm system, a warden, general counselling or support, meals or maintaining a lift? Does your home have central heating? How much? every every every every every every every every every every Does your home have a garden? Does your home have a garage? Does your home have a parking space? You Your Partner Are you living away from home at the moment? Tell us below Tell us below Why are you or your partner not living at home? When did you last live at home? When do you expect to go back home? 21

22 Part 8B About your rent and landlord (continued) What is the address of where you are living at the moment? Do you sublet your home? Have you spent at least three months living in a hostel or hostels for homeless people? Hostel Name Address Who lives there now? If you are: single, and aged 24 to 34 years old; and living alone in self-contained accommodation (this means that you do not share any rooms with anyone); and a tenant of a private landlord Please answer the questions below. Everyone else: including council and housing associations tenants, please go straight to Part 9A. Give details below. Date you entered and left Who ran the hostel? The telephone number (if known) From: To: To From: To: Are you an ex-offender who is being managed under the Multi Agency Public Protection Arrangements? We will ask MAPPA to confirm. Part 9A How we will pay your Housing Benefit You need to complete this part for help with Rent. Do you rent your property from Powys County Council or have we placed you in homeless accommodation? Complete this part Go to Part 10 Tick any of the following that apply to you. Your landlord is a housing association Your tenancy commenced before 15 February 1989 Your rent includes charges for board and attendance You live in a caravan, houseboat, mobile home or hostel Your landlord is a registered charity or a voluntary organisation and you are provided with care, support or supervision If you have ticked any of the above, the Local Housing Allowance rules do not apply to your claim, this means you can choose to have your Housing Benefit paid direct to your landlord or direct to you. Who do you want us to pay your housing benefit to? Tick one box only Direct to you Give details in Part 9B Direct to your landlord 22 Go to part 10 We will make payments to your landlord every four weeks at the end of the period in question.

23 Part 9A How we will pay your Housing Benefit (continued) If none of the different types of tenancy shown on page 21 apply, your claim is covered by the Local Housing Allowance rules. We will pay your Housing Benefit direct to you. However, we may be able to pay your benefit direct to your landlord if any one of the following apply: you cannot manage your own affairs; you are unlikely to pay your rent; you are eight weeks or more behind with your rent; or paying your landlord will help secure or maintain your tenancy. If any of these apply to you, give full reasons why you want your Housing Benefit to be paid direct to your landlord below. You will need to provide evidence to support your request. For example, a letter from your Doctor, Care Worker, etc. Part 9B About your bank account details You need to complete this part for help with Rent. If we pay your Housing Benefit to you, we will pay it every two weeks (at the end of the period in question). Payment direct into your bank or building society account is the easiest and safest way for us to pay you. You can get to the payment straight away. Tell us here about your bank or building society. We cannot pay benefit into a DWP Post Office Card Account. What name or names is the account in? Please write the name or names as they appear on the cheque book, passbook or statement. Full name of the bank or building society The sort code (We need all 6 numbers) The account number (This can be 7 to 10 numbers long) More information if it is a building society account The building society roll or reference number If you do not give us details of your bank or building society account here, we will pay you by crossed cheque. Cheques can be delayed in the post and also take up to five days to clear into your account. If you do not have a bank account that you can use to receive your Housing Benefit. You can get free and independent advice from Powys Citizens Advice Bureau about opening and managing a bank account. You can phone them on , or you can ask us below to contact them on your behalf. I agree that you can contact the Citizens Advice Bureau on my behalf and ask them to contact me about opening a bank account. Do not delay sending this form back if you do not have a bank account. 23 Signature

24 Part 10 About anything else you need to tell us You need to complete this part for help with Rent, Council Tax and School Meals Please use this space to tell us anything else you think we should know about. Part 11 About how we collect and use information You need to complete this part for help with Rent, Council Tax and School Meals We will use the information you give us in this form, and any supporting evidence you send us, to process your claim for Housing Benefit, Council Tax Reduction and Free School Meals. We may pass the information to other agencies or organisations such as the Department for Work and Pensions, the Inland Revenue, as allowed by law. This authority is under a duty to protect the public funds it administers, and to this end we may use the information you have provided on this form for the prevention and detection of fraud.we may also share this information with other bodies responsible for auditing or administering public funds for these purposes. We may check information you have provided, or information about you that someone else has provided, with other information held by us. We may also get information about you from certain third parties, or give them information to: make sure the information is accurate prevent or detect fraud and any other crime; protect public funds; support National Fraud Initiatives this may include your information being used in data matching exercises. These third parties include government departments, local authorities and private-sector companies such as banks and organisations that may lend you money. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to. We, Powys County Council, are the data controller for the purposes of the Data Protection Act Your personal information will be held and used in accordance with the requirements of the Data Protection Act If you want to know more about what information we have about you, or the way we use that information, write to us at: The Benefits Manager, Powys County Council, PO Box 71, Llandrindod Wells, Powys LD1 9AQ 24

25 Part 11 About how we collect and use information (continued) Welfare Reform data sharing The Welfare Reform Act 2012 extended our data sharing powers for prescribed purposes relating to welfare services and social security benefits. In practice, this legislation allows us to share information, subject to the other laws around data, with other local authorities, and within Powys County Council, the Department of Work and Pensions, with relevant service providers, and in limited circumstances, with social landlords. Shown below are examples of the purposes, we are most likely to be able to share your data lawfully: Benefit cap Domiciliary (non residential) care Social sector size criteria Blue Badges Homeless functions Supporting People Disabled Facility Grants Residential Care Council Tenants Sharing information with your landlord The Benefits Service and Housing Rents Section will share the information and evidence you provide to make a decision on your Housing Benefit claim. This may include personal and financial details about you and other members of your household. We will only share this information if it will help us to make a decision on your claim for benefit and help prevent rent arrears. If you do not want us to share your details with the Housing Rents Section, tick this box. Private Tenants Sharing information with your landlord Sharing information with your landlord could help us deal with your claim more quickly and reduce the risk of you falling behind with your rent because of your claim being delayed. We may need to confirm information with your landlord before we can make a decision on your claim, for example, the start date of your tenancy. In these circumstances, we can contact your landlord without your permission. By law we must tell your landlord about certain decisions we make on your claim, for example when we decide to pay your benefit to your landlord. Under the Data Protection Act 1998, we need your permission to discuss anything else. If you give us permission, we would be able to tell your landlord: that you have claimed Housing Benefit; the date you claimed; whether we have made a decision on your claim; whether we need more information from you to decide your claim, and when we asked you for the information; and whether or not your claim was successful. We will not give your landlord any information about: your personal or household circumstances; or your financial circumstances. You can take away your permission at any time. It will not affect your claim if you do not give us permission to discuss your claim with your landlord. I give you permission to share information about the progress of my Housing Benefit claim with my landlord or their representative. Signature Date Free School Meals Entitlement We will automatically work out from the information you have provided if you qualify for free school meals for any of your children. We will write and let you know. If you do not want to apply for Free School Meals even if you qualify for them, please tick here. 25

26 Part 12 Declaration You need to complete this part for help with Rent, Council Tax and School Meals Please read this declaration carefully before you sign and date it. You must sign it if you can, even if someone else has filled in the form for you. If you have a partner, they should sign this declaration as well. I understand the following: If I give information that is incorrect or incomplete, you may take action against me. This may include court action. You will use the information I have provided to process my claim for Housing Benefit and/or Council Tax Reduction and Free School Meals if appropriate. You may make any enquiries needed to check the information I have given, including checking with other sources within the Council, and other councils and organisations as allowed by law. You may use the information I have provided in connection with this and any other claim for Social Security benefits that I have made or may make. You may give some information to other organisations, such as government departments, local authorities and private-sector companies such as banks and organisations that may lend me money, if the law allows this. I know I must let the Benefits Service know straight away, in writing, about any changes in my circumstances that might affect my claim, including a change of address. I declare the information I have given on this form is correct and complete Your signature Date Your partner s signature Date Please fill in this part if you have filled in this form for the person who is claiming. I have confirmed with the person claiming that the information I have given on this form is correct. I have also explained the declaration to the person claiming. The reason I am filling in this form for the person claiming is: Signature of the person who filled in the form. Name of the person who filled in the form (in CAPITAL letters). Relationship to the person claiming. Date 26

27 Part 13 Checklist You need to complete this part for help with Rent, Council Tax and School Meals Please tick the boxes below to tell us what you are giving us as evidence to support your claim. We must see original documents, not copies. Please do not send valuable items through the post. If you can, bring it into any of our offices listed on pages 2 and 3. We will take the details we need and give you the documents back straight away. If you can, send with this form all the evidence we ask for. If you don t have all the evidence now, send the form back anyway and send the evidence later. Make sure we receive the evidence within a month, otherwise we may not be able to pay you any benefit. Evidence of identity We prefer to see a passport, driving licence with photograph, birth certificate or marriage certificate. Generally, we accept two of these, or one plus two of the following. A paper driving licence, UK Residence Permit, EEC identity card, National Insurance card, or medical card. Other documents can include recent gas, water or electric bills or bank statements. If you do not have any of these then we may need to see several other documents or even arrange to meet you. Evidence of your address Such as a recent gas or electricity bill or a TV licence. Evidence of National Insurance number Such as National Insurance number card, payslips or letters from Depart of Work & Pensions or HM Revenue & Customs. Evidence of savings and investments Such as all your bank, building society or post office books, full bank statements, or certificates for Premium Bonds, National Savings Certificates, ISAs, stocks, shares and unit trusts. We need to see this evidence for children in your household as well. The evidence you send must show details for at least the last two months. Evidence of how much you earn. We also need this for any other adults living in your home. This means your last 5 payslips if you are paid every week, your last 3 payslips if you are paid every two weeks, or your last 2 payslips if you are paid every month. We will contact your employer if you do not have these payslips. If you or your partners are self-employed, we need to see your accounts for the last financial year or, if you have been trading for less than 6 months, a summary of your trading records so far. Evidence of other income. Such as pension slips from a previous employer or a letter from the court showing how much maintenance you are getting. We need to see evidence of any money people pay you for board and lodgings. We also need this for any other adults living in your home. Evidence of allowances, benefits, credits or pensions. Such as current award notices or letters from the DWP confirming how much you get. If you do not have evidence, let us know straight away. Do not send order books through the post. We also need this for any other adults living in your home. Evidence of private rent and tenancy Such as a tenancy agreement, rent book, a letter from your landlord or rent receipts. Evidence of expenses Such as letters about parental contribution to a student, agreements or receipts from registered child minders, contributions to a private pension scheme. 27

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