Benefit service claim form

Transcription

1 Benefit service claim form Benefits Service PO Box 12 County Hall Cross Street Beverley East Riding of Yorkshire HU17 9BD Tel: (01482) Use this form to claim housing benefit and council tax support if you do not already have a claim with East Riding of Yorkshire Council. Please make sure you answer all the questions. Answer all or questions by putting a in the relevant box. You will find detailed notes to help you fill in this form on the next page. Supporting evidence If you fill in this form correctly with all the evidence required, we will process your claim more quickly. Original documents must be provided. Photocopies are not acceptable. However, if you do not have all the evidence required, please do not delay returning this form as you can normally only get benefit from the week after we receive your claim. We will contact you if we need to ask you for more evidence. It is important that you do not delay making your claim. About housing benefit and council tax support Housing benefit may be able to assist you with your rent payments but cannot pay for some services included in your rent. Council tax support can assist you with your council tax payments. You can also use this form to make a claim for free school meals. Alternative council tax support Alternative council tax support may be able to help you with your council tax payments if you are are of state pension age and live with someone on a low income who is not your partner. Your name and address (for which you are claiming) Name Address Telephone Postcode Office use only Date to customer Date to contact Date received at designated office Claim number PD01140 July 2014

2 Benefit service claim form About this form We have designed this form to be easy to fill in. It may look rather long, but we need to ensure that everyone who claims gets paid the right amount. Every part starts with a question to help you decide whether you need to fill in that part. Your views on how we can improve this form are welcome. Please tell us in part 16. If you need help to fill in the form If you need any help please contact us. Our contact details are shown on page 33 of this form. This includes our telephone number and the addresses of our customer services centres. About housing benefit and council tax support Housing benefit can pay all or part of your rent. It may also give you some extra money towards services you have to pay your landlord for, like children s play areas and cleaning shared areas. It cannot help with water charges. Council tax support can pay all or part of your council tax. Alternative council tax support Alternative council tax support is for people who may not qualify for council tax support based on their own income or capital, but who are of state pension age and share their home with someone who: is 18 or over; is on a low income, and; does not pay you rent; and is not your partner; and as a result of that person living with them the council tax payer is prevented from getting a council tax discount. If you only want to claim alternative council tax support, just fill in parts 1, 3 and parts 15 to 19 of this form. Proof We still need to see proof of some of the things you write about in this form. Where evidence is required pages are marked with this icon. If you are unsure whether to send proof of something, please contact us. We will tell you what we need to see. Remember that we cannot pay you benefit until we have seen the evidence we need. We do not recommend that you send valuable documents through the post. These can instead be taken to your local customer service centre (details of which are on page 33 of this form) where they will be photocopied and returned to you immediately. Filling in this form We will scan this form into our computer system so please use black ink. Do not use pencil and do not use correction fluid or tape - otherwise it can look as if someone else has changed the form after you completed it. Answer or questions by placing a in the relevant box - do not use a cross 7 because it can make your answers look confusing and delay the processing of your claim. What to do next When you have filled in the form and signed it, please send it with the proof we need to the benefits service address on page 1 or you can send or hand deliver it to one of the contact addresses on page 33 where your proofs can be copied. If you do not have the proof we need straightaway, please do not delay returning this form as you can normally only get benefit from the week following your claim. We will write to you if we need to ask you for more evidence. Remember that we must see original documents as proof. Photocopies are not acceptable.

3 Benefit service claim form Part 1 Page 3 If you are just claiming alternative council tax support, you only need to fill in parts 1, 3 and of this form Are you (please tick one box) a council tenant? a private tenant? a housing association or social landlord tenant? an owner occupier? other? About you and your partner Do you have a partner who normally lives with you? By partner we mean someone of the opposite or same sex who: is married to you, or who lives with you as if you are married, or is your civil partner, or who lives with you as if you are civil partners. If you have a partner, you must complete this form together. Complete all the questions about you and your partner. Your partner should also read and sign the declaration on page 29. You Your partner Surname or family name Other names Any other names you or your partner have used Title (Mr, Mrs, Miss, Ms, other) Mr Mrs Ms Miss Mr Mrs Ms Miss Other Other Have you or your partner ever been awarded Universal Credit?

4 Page 4 Part 1 About you and your partner continued You Your partner What date did you move to this address? Phone number (this may help us pay your claim quicker.) If the number above is for the person who has helped you claim benefit, please enter their name. address (this may help us pay your claim quicker.) Date of birth Gender Male Female Male Female National Insurance (NI) number You can find this on payslips, your P60 or P45, or letters from the Tax Office, Department for Work and Pensions or the Tax Credits office. We cannot normally pay your claim if we do not have your NI number. We need to see proof of this. If you or your partner do not have a National Insurance number, or cannot find it, please tick this box. Letters Numbers Numbers Numbers Letter Letters Numbers Numbers Numbers Letter Are you or your partner registered blind? We must see proof of National Insurance number(s). Read the checklist in part 19 of this form to see what you can use as evidence.

5 About you and your partner continued Part 1 Page 5 You Your partner Have you or your partner claimed housing benefit, council tax benefit or council tax support from East Riding of Yorkshire Council before? Please provide the last address where you and your partner lived before you moved to the address you are claiming for. Postcode Please tell us if you were either a homeowner, private tenant or council tenant at this address. What is your nationality? Have you or your partner ever lived outside the British Isles? By British Isles we mean the UK, Republic of Ireland, Channel Islands and the Isle of Man. If yes, when did you and/or your partner most recently come to live in the British Isles? Are you or your partner a student? Tell us if this is full time or part time. Tell us if this is full time or part time. Full time Part time Full time Part time Do you or your partner make a contribution towards a student s loan, grant or living expenses? We will contact you if we need any more information

6 Page 6 Part 2 About your children Page 6 We need to know about any children who live with you and are: Aged under 16, or Aged 16 or over and you or someone else receives Child Benefit for them. Details of children who are the responsibility of you or your partner. If you or your partner get Child Benefit, please write your Child Benefit number in this box, if known. Your Child Benefit reference number beginning CHB can be found at the top right of your Child Benefit letters and on your bank statement. If you do not have any children living with you go to part 3. Use this part of the form to provide details of up to four children. If you have more than four children living with you, please provide the same information for each additional child in part 16. First Child Second Child Child s surname Child s other name(s) Child s gender and date of birth Male Female Male Female Is there another address where the child stays or lives, apart from the address you are claiming for? Please provide details and say why the child stays there (e.g. shared custody). Who gets Child Benefit for this child? Do you or your partner receive any fostering or adoption payments for this child? Is this child registered blind? Does this child get Disability Living Allowance or Personal Independence Payments? Answer even if someone else receives these benefits on behalf of the child. We must see proof of Child Benefit and any disability benefits paid for children

7 About your children Part 2 Page 7 Third Child Fourth Child Child s surname Child s other name Child s gender and date of birth Male Female Male Female Is there another address where the child stays or lives, apart from the address you are claiming for? Please provide details and say why the child stays there (e.g. shared custody). Who gets Child Benefit for this child? Do you or your partner receive any fostering or adoption payments for this child? Is this child registered blind? Does this child get Disability Living Allowance or Personal Independence Payments? Answer yes even if someone else receives these benefits on behalf of the child. About paying for child care Do you or your partner pay for a registered childminder, a nursery or an after-school club? Go to page 8 How much do you/your partner pay? Do you/your partner only pay during school term time? every For which of your children? What is the name, address and OFSTED number (if known) of the provider(s)? If you use more than two child care providers, please use part 16 to tell us about the others If you provide evidence of child care costs we may be able to increase the amount of benefit you receive. Read the checklist in part 19 of this form to see what you can use as evidence.

8 Page 8 Part 2 Free School Meals Page 6 Only families who meet the following criteria will be eligible for free school meals: You receive Jobseekers Allowance (Income-based) or Income Support or Pension Credit (Guarantee Credit) or Employment and Support Allowance (Income-related); or You receive Child Tax Credit and do not receive Working Tax Credit, and you have a low income. Do you wish to claim for free school meals? Please tick the required option. Please give the name of the school that each of your children attend: Child School

9 About other people who live with you Part 3 Page 9 Tell us about other people that live with you: For example any other adult or young person who lives with you. To tell us about more than three people, use part 16. Is there anyone else who normally lives with you? Go to part 4 Fill in this part First Person Second Person Third Person Surname Other name(s) Relationship to you Parents, son, daughter, care worker, friend, foster child, boarder or subtenant. Boarders are people, not close relatives, who pay rent that includes an amount for meals. Sub-tenants are people, not relatives, who pay rent that does not include an amount for meals. Is this person the partner of anyone else who lives with you? If so, say who. By partner we mean spouse, civil partner or living together as if they were a spouse or civil partner. Do they pay rent money for board and lodgings to you or your partner? If so, how much? Please tick no if this is paid by an adult friend or relative. Does this include food? Are they a joint owner or joint tenant who shares the rent or council tax with you? Date of birth Partner of per week You do not need to answer any further questions in part 3 about a person who pays you rent or is a joint tenant with you. Partner of Partner of per week per week Do they get any of the following benefits: Income Support, Income-based Jobseekers Allowance, Income -related Employment and Support Allowance, Universal Credit or Pension Credit? We need to see proof of this We need to see proof of this We need to see proof of this Do they get Disability Living Allowance, Personal Independence Payments or Attendance Allowance? We need to see proof of this We need to see proof of this We need to see proof of this It will help us to check their entitlement to the above benefits if you can provide their National Insurance. Letters Numbers Numbers Numbers Letters Letters Numbers Numbers Numbers Letters Letters Numbers Numbers Numbers Letters

10 Page 10 Part 3 About other people who live with you continued Page 6 First Person continued Second Person continued Third Person continued Are they registered blind? We need to see proof of this We need to see proof of this We need to see proof of this Are they a full-time student or on a training scheme? We need to see proof of this We need to see proof of this We need to see proof of this Do they work? If they work, how many hours do they normally work each week? Tell us their gross Tell us their gross Tell us their gross earnings before earnings before earnings before hrs deductions hrs deductions hrs deductions We need to see proof of earnings We need to see proof of earnings We need to see proof of earnings Do they have any other income? Make sure that you tell us about all other income they have. This includes any benefits or allowances you have not already mentioned and dividends or interest from savings. Tell us about it below If they have more than two other items of income, use part 16 Tell us about it below If they have more than two other items of income, use part 16 Tell us about it below If they have more than two other items of income, use part What is this income? How much is it before deductions? 2. What is this income? How much is it before deductions? Is this person currently living or staying away from your home temporarily? If so, tell us the date they went away and the reason for their absence.

11 About income from benefits Part 4 Page 11 You Your partner Are you or your partner getting Disability Living Allowance, Personal Independence Payments, Attendance Allowance or Constant Attendance Allowance? We need to see proof of this We need to see proof of this Are you or your partner getting Income Support, Income-based Jobseekers Allowance, Income-related Employment and Support Allowance or Pension Credit (Guarantee Credit)? Are you or your partner getting Universal Credit? Are you or your partner getting Pension Credit (Savings Credit) only, without Guarantee Credit? Maintenance (for you/your partner or your children)? Do you receive any other government benefits or allowances not already mentioned above? If please provide details in part 16 If please provide details in part 16 If please provide details in part 16 If please provide details in part 16 We must see evidence of your benefits, allowances or pension before we decide how much benefit you can get. Read the checklist in part 19 to see what you can use as evidence.

12 Page 12 Part 5 About being self-employed Page 6 Are you or your partner self-employed? By self-employed we mean working as a sole trader or in a partnership, normally paying Class 2 and 4 National Insurance contributions. If you are a director of a limited company you should tell us about this in part 7. Go to part 6 You Answer the questions on this page. You must send us your trading account for the last financial year. If you have only recently set up the business and do not have a full year s accounts, you will need to complete a self employed income declaration form. These are available from customer services or from Your partner What kind of work do you do? When did the business start? Do you or your partner work under a business name that is different from your personal name? If yes, please give the business name. Do you or your partner have a business address that is different from the address you are claiming for? If yes, please give details. How many hours a week do you usually work? Do you pay into a private pension scheme? How much and how often? How much and how often? every every We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist in part 19 of the form to see what you can use as evidence.

13 About working for an employer Part 6 Page 13 Do you or your partner work for an employer? Answer and complete this part if you or your partner are in paid employment including if you are currently absent from work and getting sick pay, adoption pay, maternity or paternity pay. But do not use this part to tell us about working as a director of a limited company. Go to part 7 Answer the questions on this page. If you or your partner work for more than one employer, tell us in part 16. You Your partner What is the employer s name and address? Postcode Postcode When did you start this job? How often do you get paid? weekly fortnightly 4 weekly monthly weekly fortnightly 4 weekly monthly How many hours a week do you usually work? When will your next pay rise be? (if known) What is your payroll number? We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist in part 19 of the form to see what you can use as evidence.

14 Page 14 Part 6 About working for an employer continued Page 6 You Your partner Do you or your partner s earnings change according to how many hours you work every week or month? Do you or your partner receive any tips, bonuses or other additions?, earnings change with hours worked, earnings are the same every week/month Please give details below., earnings change with hours worked, earnings are the same every week/month Please give details below. Do you or your partner pay into a private or company pension scheme? This includes a scheme run by your employer or a private scheme that you pay into separately. Are you or your partner currently receiving any of the following: Sick pay (including Statutory Sick Pay or other sick pay from your employer). Maternity pay (including Statutory Maternity Pay or other maternity pay from your employer). Paternity pay (including Statutory Paternity Pay or other paternity pay from your employer). Adoption pay (including Statutory Adoption Pay or other adoption pay from your employer). How much and how often? How much and how often? every every We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist in part 19 of the form to see what you can use as evidence.

15 About any other work Part 7 Page 15 You Your partner Do you or your partner work as a director of a limited company? We will write to you about this. We will write to you about this. Do you or your partner hold elected office (for example, as a local Councillor)? We will write to you about this. We will write to you about this. Do you or your partner do any other paid or unpaid work that you have not already mentioned on this form? Please give details below. Please give details below. We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist in part 19 of the form to see what you can use as evidence.

16 Page 16 Part 8 About benefits, pensions and allowances Page 6 Please tick the box next to each benefit, credit, pension or allowance that you or your partner are getting or waiting to hear about. Tick the box for each benefit, credit, pension or allowance that you or your partner are neither getting or waiting to hear about. You Your partner Child Tax Credit Working Tax Credit Jobseekers Allowance (Contribution-based) Employment & Support Allowance (Contribution-based) Incapacity Benefit State Retirement Pension Carers Allowance Maternity Allowance Bereavement Allowance Widowed Parent s Allowance Widow s Pension Industrial Injuries Benefit Industrial Death Benefit Reduced Earnings Allowance Severe Disablement Allowance War Disablement Pension Armed Forces Compensation Scheme Pension who do you receive this for? who do you receive this for? Others (please specify) Benefits received by other people who provide you or your partner with care. Does anyone get or have underlying entitlement to carers allowance for caring for you or your partner? We must see proof of all benefits. Read the checklist in part 19 of this form to see what you can use as evidence.

17 About other money coming in Part 9 Page 17 Is there a private pension or work pension that you or your partner could take now if you wanted to, but you have decided to delay drawing? Tell us the name and address of the pension provider and, if possible, your policy/membership number. Do you or your partner have any money coming in (or expect to have some money coming in) that you have not already told us about on this form? Examples of income that you should put in this part: Occupational or work pensions, annuities, student grant or loan, money from a trust fund, state benefits or pensions from another country, rent from another property that you rent out. Also include money that is paid directly to someone else on your behalf (e.g. if someone pays your rent or mortgage for you). Go to part 10. Answer the questions on this page. (You do not need to tell us about payments from the Independent Living Fund, the Eileen Trust or the MacFarlane Trust). Other money 1 Other money 2 Other money 3 Name of other income Who gets it? You Your partner You Your partner You Your partner How is the money paid? How much is it? How often is it paid? Every Every Every When did it start? When is it likely to go up? If you or your partner have any other income which you have not yet told us about please provide details on page 27. We must see proof of all income. Read the checklist in part 19 of this form to see what you can use as evidence.

18 Page 18 Part 10 About all bank accounts, savings, investments and property Page 6 Do you or your partner have any savings, investments, debts owed to you, land or property in the UK or abroad? Answer the questions in this part Go to part 11 Money in bank, building society and post office accounts etc. This includes current accounts held at a bank, building society or post office. If you and your partner have more than four accounts, use part 16 to tell us about the others. Account 1: Name of bank etc: Type of account: Account balance: Name of account holder: Account number: Account 2: Name of bank etc: Type of account: Account balance: Name of account holder: Account number: Account 3: Name of bank etc: Type of account: Account balance: Name of account holder: Account number: Account 4: Name of bank etc: Type of account: Account balance: Name of account holder: Account number: Do you or your partner have any Premium Bonds? Value: Do you or your partner have any National Savings Certificates? Details: Issue: Number held: Issue: Number held: Issue: Number held: Do you having any savings in cash? We must see proof of all capital. Read the checklist in part 19 of this form to see what you can use as evidence.

19 About all bank accounts, savings, investments and property continued Part 10 Page 19 Do you or your partner have any ISAs, PEPs or TESSAs? Name/type: Approximate value You Give the details below: Name/type: Approximate value Your partner Give the details below: Name/type: Approximate value Do you or your partner have any other bonds, gilts or cash savings of any kind? Name/type: Approximate value Give the details below: Name/type: Approximate value Give the details below: Name/type: Approximate value Do you or your partner have shares? Name/type: Approximate value Give the details below: Name/type: Approximate value Give the details below: Name/type: Approximate value Do you or your partner own any land or property apart from the home you are claiming for? We will write to you Do you or your partner s savings and investments include money that came from any of the following sources? We may have to write to you about this. Money from the sale of property? An insurance policy? An improvement or repair loan? A charitable donation? Compensation for a personal injury? Compensation for atrocities committed by Germany in World War II? The vcjd (Creutzfeldt-Jakob Disease) Trust? Compensation from the Far Eastern Prisoners of War scheme? Arrears of the benefits listed below? Housing Benefit, Council Tax Benefit, Income Support, Income-based Jobseekers Allowance, Income-related Employment and Support Allowance, Child Tax Credit, Working Tax Credit, Pension Credit, Disability Living Allowance, Attendance Allowance, Attendance/Mobility Supplement. We must see evidence of savings, investments or property before we can decide how much benefit you can get. Read the checklist in part 19 of the form to see what you can use as evidence.

20 Page 20 Part 11 About where you live Page 6 Did you ever own your home before you started to rent it? If yes, we may write to you about this. Do you or your partner have a shared ownership lease? By shared ownership we mean that you own a percentage of the equity in your home and your landlord owns the rest. Do you or your partner own, or jointly own, the property you are claiming for? By own we mean freehold, or a long lease that was granted for at least 21 years when it started. Are you or your partner a council tenant, housing association tenant or a tenant of a registered social landlord? If yes, go to part 13. We will write to you. If yes, go to part 15. If yes, go to part 12. You must answer the remaining questions in this part if you or your partner rent your home from a private landlord. What sort of building do you live in? Tick one box only Is the property let as: Detached house Semi-detached house Terraced house Maisonette Bungalow Flat in a house Furnished Partly Furnished Flat in a block Flat over a shop Bedsit, room or studio flat Hostel Caravan, mobile home or houseboat Minimally Furnished Board and lodgings Hotel Residential nursing home Residential care home Other give details Unfurnished Does your home have: Central heating? A garage? A garden? A parking space? Who is responsible for decorating your home? Tenant Landlord Don t know Do you and your household only occupy part of the building you have ticked? Room number if known. If yes, where in the building do you live? At the front In the middle At the back How many floors are there in the property? Which floor or floors do you live on? For example, ground floor, first floor, whole house.

21 About your tenancy Part 12 Page 21 How many of the following kinds of room are there in the whole building? (If you live in a flat/bedsit, please answer these questions regarding your flat/bedsit only). In the whole building Just for you and your household That you share with other people Bedrooms Bedsitting rooms Living rooms Dining rooms Bathrooms or shower rooms Separate toilets Kitchens Other rooms Describe the other rooms Do you or your partner have a carer who lives somewhere else, but provides care overnight in your home?

22 Page 22 Part 13 About rent Page 6 Are you or your partner a council tenant? If yes, go to part 14. Are you or your partner charged rent for your home? Rent includes any payments you have to make to a landlord for permission to live in your home. Tick if you would pay rent but you already get housing benefit. If no, go to part 15. If yes, answer the questions in this part. How much rent are you charged and how often? every Who is liable for council tax at this address? What is the landlord s full name and business address? By landlord we mean a person or organisation with whom you or your partner have a tenancy or licence agreement - this is usually the owner of the property. Name Address Postcode Telephone If the landlord uses a managing agent, please provide the managing agent s full name and business address. The managing agent is usually the person or company you pay rent to and contact about things like repairs. Name Address Postcode Telephone Are you, your partner or any of you or your partner s children related to the landlord or managing agent? By related we mean by blood or by marriage/civil partnership, even if the marriage/civil partnership has ended, e.g. father, daughter, mother-in-law, step-son, grandson, sister, aunt. Were you or your partner ever the spouse, civil partner or cohabiting (live-in) partner of the landlord or managing agent? What period does the current or most recent From tenancy agreement cover? Please give details of the relationship: We will write to you about this. To is the landlord s/agent s On what date did you or your partner s first tenancy agreement at this address begin?

23 About rent continued Page 6 Part 13 Page 23 Is someone else (apart from you and your partner) jointly liable for the rent in your home? By jointly liable we mean someone who is a joint tenant or licensee in the agreement that you have with your landlord, even if they do not currently live with you. Tell us about up to three joint payers below. Use page 27 if there are more than three. You and your partner s share of the rent Share of the rent paid by joint payer 1 Share of the rent paid by joint payer 2 Share of the rent paid by joint payer 3 per per per per Has the rent been registered as a fair rent by a Rent Officer? Are there any weeks or months of the year when the rent does not have to be paid? Your landlord might call this a rent-free period. Are you or your partner behind with the rent? Please send us the notice of registration form RO5. Please say how many weeks/months. By how many weeks/months? Weeks/Months Weeks/Months Does the rent include money for any of the following services: Water charges Laundry service (for example, clean sheets or towels) Fuel (gas/electric) for: Cleaning rooms or windows Heating Personal care or support Hot water Subscription TV service Cooking Alarm system Lighting Any other services Please provide details: Meals Breakfast only Full board (breakfast, midday meal and evening meal) Part board (any other meals) We must see evidence of your rent and tenancy before we can decide how much benefit you can get. Read the checklist in the guidance notes to see what you can use as evidence.

24 Page 24 Part 14 How your benefit will be paid and the choices you have Page 6 If you or your partner are a council tenant, we will pay any housing benefit you are awarded into your council rent account. If you or your partner are a housing association tenant, you can normally choose whether your housing benefit is paid directly to your landlord or paid to you. If neither you nor your partner are a housing association tenant or a council tenant, we will normally pay your housing benefit by transferring the money into a bank account that you nominate, unless there is an important reason why we should not do so (supporting evidence may be required). Please use the space below to provide the information we need to decide how to pay your housing benefit (supporting evidence may be required). Tick the relevant box: Please pay my housing benefit into the bank account nominated below This should normally be you and/or your partner s bank account. If you want us to pay someone else (such as a friend or relative), there is a space in the bank account details area below where you can explain why. Please pay my housing benefit to my landlord because: I am a housing association tenant/my partner is a housing association tenant and I prefer you to pay my benefit to the landlord. My partner and I are not housing association tenants, but I would prefer you to pay my benefit to the landlord because: Bank account details Name(s) of account holder(s): If the account holder is someone other than you or your partner, please say why: Name of bank/building society: Sort code: Account type (e.g. current, deposit): Account number:

25 About living or staying at another address Part 15 Page 25 Do you or your partner have another home somewhere else (as well as the one you are claiming for)? This includes a home in the UK or abroad, even if you do not pay rent for it. If yes, do you or your partner pay rent for the other home? How much? every What is the address of the other home? Postcode Are you or your partner staying away from the home you are claiming for? Tell us about it below. Staying away means you are spending nights away from home and not returning during the day time. Go to part 16. Who is staying away from home? Just you Just your partner You and your partner Why are you/your partner staying away from home? Give the reasons in the box below - for example in hospital, visiting relatives, studying. On what date did the absence begin? On what date do you/your partner expect to return home? Please provide the address where you/your partner are staying. Postcode

26 Page 26 Part 16 Backdating and any other information Page 6 We can usually award housing benefit or council tax support from the Monday after the day we receive your claim. Sometimes we can pay your claim from an earlier date if you have a good reason for not claiming earlier. Depending on your circumstances your claim can be backdated for up to six months. If you wish us to consider backdating your claim please provide proof of your income and capital for the backdate period and answer the two questions below. What date would you like your claim backdated to? Reasons for delay in claiming (please attach any relevant evidence, for example, letters from doctor, social worker, support worker). Please note that we need to see evidence of your income and capital during the period you want to claim backdating for.

27 Backdating and any other information continued Part 16 Page 27 Other Information Use the space below to tell us about anything you did not have room to put in the rest of this claim form, or anything else you think we should know that we have not asked about. Other information continued. Sports and leisure concessions People entitled to housing benefit or council tax support can use council managed sports and leisure centres throughout the East Riding at a discount one-third of the normal full price for many activities. If you wish to apply for this concession please call into your local leisure centre or customer service centre. Supporting people services If you are receiving Supporting People services, the benefit section may be able to provide information which could greatly improve the service that you receive. Please sign in the box below to authorise the benefit section to pass details of your claim or a change of your address, to the Supporting People Team.

28 Page 28 Part 16 Backdating and any other information Page 6 Sharing information with your landlord or managing agent If your housing benefit is paid directly to the landlord or managing agent, we have to tell them some basic information such as the amount of benefit you are entitled to and when from. If there is an overpayment of benefit to your landlord or agent, we have to tell them how it happened. We might also have to contact your landlord to check that the information in this form is accurate, such as the date when the tenancy began. Other than that, we will not disclose any information to your landlord or managing agent without your permission. Sharing information with your landlord or agent 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. If you have no objection to us sharing information with your landlord or agent in order to help us deal with your claim more quickly, you can authorise us to do so in the space below. Sharing information with others If there is someone else helping you with your claim (such as a friend, relative, support worker or social worker) and you are happy for them to deal with us on your behalf, please provide their name and contact details in the space below. I give my permission for East Riding of Yorkshire Council to share information about my housing benefit and council tax support claim with: (Tick any that apply and sign in the bottom box to confirm your permission). The landlord The landlord s managing agent Data Protection Act 1998: How we collect and use information We will use the information you give in this form, and in any supporting evidence that you send, to process your claim for housing benefit and council tax support. We may share information with other organisations involved in the administration of benefits, in particular the Department for Work and Pensions, other local authorities and Her Majesty s Revenue and Customs; and we may obtain information about you from those organisations from time to time in order to process your claim and ensure that your award remains correct. East Riding of Yorkshire Council is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. Where the Data Protection Act allows it, we may: use the information you have provided for other purposes, such as council tax collection; and disclose the information to third parties for lawful purposes, such as the prevention or detection of crime. East Riding of Yorkshire Council is the data controller for the information on this form for the purposes of the Data Protection Act. Information will be held for at least three years, and for as long as necessary after that to fulfil the purposes described above. If you want to know more about the information we hold about you or the way we use it, please contact us (see pages 1 and 33 for contact details). The person named below Their address: Their name: Their connection with you: Their telephone/ details: Your signature Postcode

29 Declarations Part 17 Page 29 Your declaration as the person making the claim I am the person claiming housing benefit and council tax support. I declare that the information I have given on this form is correct and complete. I understand that I must inform East Riding of Yorkshire Council of any change in my circumstances and/or any change to the information I have provided in this form as soon as a change occurs. I understand I must inform East Riding of Yorkshire Council in writing at one of the contact addresses provided on pages 1 and 33 of this form. I have read the examples at the bottom of this page regarding the changes that I must inform the council about. I understand that if I give information that is inaccurate or incomplete, or if I fail to inform East Riding of Yorkshire Council benefits service about a change of circumstance, I could be prosecuted. I have read and understand the declaration Declaration by the person who filled in the form for you I am the person who filled in this claim form on behalf of the person making the claim. I declare that I have as far as possible confirmed with the person making the claim that the information given on this form is correct and complete. Name: Address: Signature Postcode: Date Signature of person making the claim: Date Your partner s declaration I am the partner of the person making this claim for housing benefit and council tax support. I have read the information that my partner has given on this form and I declare that the information is correct and complete. I have read the examples at the bottom of this page regarding the changes that my partner must inform the council about. I understand that if I cause or allow my partner to give information that is inaccurate or incomplete, or if I cause or allow my partner to fail to inform East Riding of Yorkshire Council about a change in circumstances I could be prosecuted. Signature of partner: Date Changes of circumstances You must inform East Riding of Yorkshire Council benefits service in writing immediately if you have a change of circumstance that might affect your housing benefit and council tax support. Changes can be reported to the addresses shown on pages 1 and 33 of this form. Examples of the changes that you must report: You, your partner or someone in your household stops getting Jobseekers Allowance, Employment and Support Allowance or Income Support. The earnings, pensions, benefits, tax credits, pension credits or other income of anyone in your household changes (including your income and your partner s income.) Either you or your partner s savings or investments change. If you, your partner or anyone else moves into your home, moves out or goes to stay temporarily at another address. A child in your household leaves school or college. You, your partner or someone in your household starts work. Generally, if anything that you have told us about on this form is no longer correct.

30 Page 30 Part 18 Monitoring our services Page 6 Monitoring our services East Riding of Yorkshire Council works towards eliminating discrimination and promoting equal opportunities. Collecting the following information can help us achieve this. Data collected will be used to help us to plan and deliver services more effectively to individuals and service users. It will also be used to report on the needs of different groups of people. Information provided will be treated confidentially in accordance with the Data Protection Act National Insurance Number Letters Numbers Numbers Numbers Letter How would you describe your ethnic origin? White: British White: Irish White: Other White Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asian Mixed: Other Asian or Asian British: Indian Asian or Asian British: Pakistani Other ethnic group (please describe) Asian or Asian British: Bangladeshi Asian or Asian British: Other Asian Black or Black British: Caribbean Black or Black British: African Black or Black British: Other Black Chinese Gypsy/Traveller Prefer not to say Are you? Male Female What is your age group? 15 or under and over How would you describe your sexuality? Lesbian or Gay Heterosexual Bisexual Prefer not to say Other

31 Monitoring our services continued Part 18 Page 31 Do you consider yourself to be a disabled person? If you have answered yes please tick which of the following apply (you may tick more than one): The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities A physical impairment A visual impairment A hearing impairment Mental health issues A learning difficulty A specific learning difficulty (For example: dyslexia) Deaf British Sign Language user Long term condition For example diabetes, multiple sclerosis, living with HIV or cancer What is your religion? What is your preferred language of communication? Christian Spoken Written Buddhist Hindu Jewish Muslim Sikh English British Sign Language Other Please specify: English Other Please specify: religion Prefer not to say Any other religion Please describe: Do you prefer to receive communications in a form or type that is different from standard written format? If yes, please specify which format: Large print Audio tape Visual (e.g. video) Easy English Braille Compact disc (CD) Text phone/texbox Type Talk Video Phone BSL video Computer disc (floppy) Other Please specify: Thank you for taking the time to provide us with this monitoring information.

32 Page 32 Part 19 Checklist Page 6 Do not send valuable documents through the post. These can be taken to your local customer service centre where they will be photocopied or scanned and returned to you immediately. If you do not have the proofs needed to hand, you should still return this form or you may lose benefit. Please provide the proof as soon as possible. If you cannot provide the proof needed within one month you must let us know. If you do not let us know you may not get any benefit. A landlord form and earnings certificate are provided with this form. Additional earning s certificates are available from those council offices listed on page 33 or can be downloaded at Evidence of identity & National Insurance Number If this is the first time that you have made a claim with us, or you have never been asked to provide this previously, we need to see proof of National Insurance number and identity for both you and your partner. For you and your partner please provide one original document for National Insurance number and one original document for identity from the list below. These must not be photocopies. National Insurance Number DWP letters P45 or P60 Pay slips National Insurance Number card Former employers pension letter or remittance slip showing National Insurance Number Bank statements showing payments annotated with the National Insurance Number Identity Current passport Driving licence in photocard format Recent gas, electricity, water or telephone bill (not mobile telephone) paid in yours or your partner s name Bank statement (for current address) Birth certificate Letters from government department (e.g. DWP, Home Office) European Member State Identity Card Marriage certificate Divorce or annulment papers Medical card Life assurance or insurance policies Letter from a solicitor, social worker or probation officer Certificate of Employment in HM Forces or Merchant Navy Evidence of capital, savings & investments We need to see proof of any savings, capital or investments that you and your partner have. Below is a list of capital items along with the different types of proof we need to see for each. These proofs must show up-to-date balances and interest:- Bank or building society account - current statement(s) showing the account holder s name, account number and balance. These must also show all transactions over the last two full calendar months. Internet banking - an original screen print showing the account holder s name, account number and balance. These must also show all transactions over the last two full calendar months. Deposit/ISA (cash deposit form) accounts - we need to see the accounts book, annual statement (both of which should be updated to include the latest interest payment) or a letter from the bank or building society showing the current balance. Investment Bonds - statement or letter showing current balance or value of investment. Premium Bonds - we need to see the Premium Bond certificates or a letter confirming the current investment. National Savings Certificates - certificate or letter confirming the number of units and the issue number. Stocks and shares - original share certificate or dividend statement or letter from the company, all of which must show the number of shares held and in which company. Unit Trusts, PEP s, ISA s (Investment form) and TESSA s - the latest valuation statement showing the amount invested or up to date passbook dependant on which type of investment has been purchased. Land or property (but not the home you live in). The benefit service will send you a separate form to fill in if you have any land or property. Evidence of earnings We need to see the following as proof of earnings for you and your partner:- Last 2 consecutive pay slips (if you are paid monthly or 4 weekly) or the last 3 consecutive pay slips (if you are paid fortnightly) or the last 5 consecutive pay slips (if you are paid weekly). Completed Earnings Certificate (this must have a company stamp or be accompanied with a letter on company headed paper). If you have just started work and cannot provide all of the payslips that we require, please supply those that you currently have. We will require all of them as you receive them but may be able to calculate your benefit based on the payslips that you currently have.

33 Checklist continued Part 19 Page 33 Evidence of other income We need to see proof of any other money that you and your partner have coming in. The type of proof we need includes:- Bank statements showing the last 2 payments of an income. For students we require documents from the Student Loans Company showing the financial assessment and term times. Child Support Agency letter if paid into the bank. Maintenance: we do not need to know about any maintenance that you receive for your children. However if you receive maintenance for any other reason we need to see proof of this. This proof may include a letter from the person or organisation paying the maintenance or a bank statement showing payments being made. Rental income from other properties. Evidence of benefits, pensions, tax credits & allowances We need to see proof of any benefits and pensions that you and your partner get. We need to see one of the following for each type of income:- All pages of your latest benefit, pension or tax credit award letter. Bank statement(s) showing the last 2 payments if paid into bank. For a former employers or private pension we require a recent letter outlining the amount paid or a recent remittance slip. Evidence of rent You do not need to provide proof if you rent your home from the council. If you rent your home from a Housing Association or private landlord we need to see one of the following:- Your tenancy agreement. A completed landlord form (available from the benefits service or customer service centre). This must be signed by both the landlord and the tenant. Your rent book or rent receipts. Evidence of money paid out We need to see proof of any money that you and your partner pay out towards pensions, childcare or a parental contribution to a student grant. This list below shows which proofs we need to see. Pension policy letters or payslips that show the amount being paid into a pension scheme. Your last 2 months bank statements if the pension is paid from a bank account. Invoice from registered childcare provider or a letter outlining the payments, both of which must show the Ofsted reference number of the childcare provider. Student award notice. Contact addresses and further advice Telephone: (01482) benefit.assessments@eastriding.gov.uk Website: You can also contact us in person or by post at any one of the offices below: Anlaby 17 Hull Road Beverley Cross Street Bridlington Town Hall, Quay Road Brough Petuaria Centre, Centurion Way Cottingham Civic Hall, Market Green Driffield Council Offices, West Garth Goole Council Offices, Church Street Hedon 2 New Road Hessle Peeler House, Ferriby Road Hessle (from December 2013) Hessle Library, Southgate Hornsea 75 Newbegin Howden 69 Hailgate Market Weighton The Wicstun Centre, 14 Beverley Road Pocklington Pocela Centre, 23 Railway Street Withernsea Queen Street Complaints, comments or compliments East Riding of Yorkshire Council is committed to providing a high quality service to all of our customers. We welcome feedback from customers and if you would like to submit a complaint, comment or compliment, further information can be obtained by contacting us using the details shown on this page. Anyone claiming housing benefit and council tax support from East Riding of Yorkshire Council can get independent advice on claiming or making an appeal. A list of advice agencies can be obtained by contacting us using the details shown on this page. This is a housing benefit and council tax support claim form. East Riding of Yorkshire Council will, on request, provide this document in Braille, LARGE PRINT or an audio version or, if English is not your first language and you need a translation, we can get one for you.