This form is to be used to apply for Discretionary Housing Payments and Council Tax Discretionary Fund payments only

Transcription

1 Benefit Service APPLICATION FOR HOUSING & COUNCIL TAX DISCRETIONARY PAYMENTS This form is to be used to apply for Discretionary Housing Payments and Council Tax Discretionary Fund payments only Discretionary Housing Payments (DHP) & Council Tax Discretionary Fund payments (CTDF) are made from separate funds each with a limited budget. These funds support people who need extra help with their rent or council tax when housing benefit/local housing allowance/universal credit doesn t cover the full amount These payments are awarded as a short term measure to help claimants in extremely difficult circumstances. It is strongly recommended that you seek support to achieve a long term solution. All those wishing to claim should complete sections A and B. For help to pay your council tax please also complete section C and for those needing help to pay rent, please complete Section D. If you are applying for both payments complete all sections of this form Name: Address: FOR OFFICE USE ONLY: PIN/CRN: CTAX REF: Post code: Daytime telephone number: Home: Work: Mobile: DATE OF ISSUE: DATE RECEIVED: PART A ABOUT YOUR APPLICATION What do you need help with (please tick the appropriate box): Rent Council Tax Both DHP CDHF Form V2.0 September

2 Please provide details of the reason(s) for your application: Please tick the box that closely resembles the reason why you are currently suffering financial hardship: Size Criteria rule changes Changes to Local Benefit Cap Personal in social housing Housing circumstances Allowance causing hardship If you have ticked size criteria can you please confirm if you: Are a registered Foster Have a property Have a disabled child Carer significantly adapted for a disability Please tell us about any other details to support your hardship application If you need an award to be backdated, please tell us the date you wish to claim from and why you did not claim earlier: Date PART B Income and Expenditure Please list all your income details Income (self) (partner) How often received, ie, weekly, monthly Office use only Weekly Wages/salary (take home pay) Income Support Job Seekers Allowance DHP CDHF Form V2.0 September

3 Income (self) (partner) How often received, ie, weekly, monthly Office use only Weekly Universal Credit Child benefit Working tax credit Child tax credit Pension credit Employment and Support Allowance DLA Care/PIP Living DLA Mobility/PIP Mobility Pension - State Retirement Pension - Private/Works/Occupational Other benefit (please state which) Savings and investments, eg, bank/building society accounts Money from other adults in the house, eg, son, daughter. Board and lodgings Other income, eg, maintenance (please state where from) TOTAL Please list all your spending details Outgoings (you may be required to provide proof of your expenditure) How often do you spend the money, eg, weekly, fortnightly, monthly, yearly OFFICE USE ONLY Weekly amount Mortgage Second mortgage Rent shortfall Rent arrears Council tax DHP CDHF Form V2.0 September

4 Outgoings (you may be required to provide proof of your expenditure) How often do you spend the money, eg, weekly, fortnightly, monthly, yearly OFFICE USE ONLY Weekly amount Gas Gas arrears Electricity Electricity arrears Water rates Water rates arrears Housekeeping (food, etc) Clothing Maintenance Court fines Insurance - car Insurance - house (contents and buildings) Insurance - personal TV licence TV rental Sky or Cable TV Internet Entertainment Travel - bus/train fares Travel - taxi fares Car - finance Car - fuel Car - road tax Telephone - landline Telephone - mobile Secured loan - owing Total DHP CDHF Form V2.0 September

5 Outgoings (you may be required to provide proof of your expenditure) How often do you spend the money, eg, weekly, fortnightly, monthly, yearly OFFICE USE ONLY Weekly amount Credit card - owing: Total Store card - owing: Total Catalogues - owing: Total Other living costs (please specify, eg, child care costs, medical costs etc) TOTAL Please tell us anything else about why you will suffer financial difficulties without any extra help. PART C COUNCIL TAX HARDSHIP You cannot make a claim for council tax hardship for charges applied to your account for non-payment, such as liability charges, court costs or bailiff charges. Please tell us how long you will need this support for: Is the council tax bill for your property in your name? Yes No If yes, please state your Council Tax reference or account number Are you in arrears with your Council Tax? Yes No DHP CDHF Form V2.0 September

6 Please explain why you are in arrears with your Council Tax Account: Do you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more? If you pay additional expenses due to health reasons, please tell us here. Weekly Council Tax amount requested: From Date: PART D DISCRETIONARY HOUSING PAYMENT What do you need help with (please tick each box that is appropriate): Rent Deposit Rent in advance Removal costs Please tell us how long you will need this help for: Less than 13 weeks 13 weeks 26 weeks One off payment If less than 13 weeks please specify weeks Weekly DHP amount requested: From: If you need help with a rent deposit, please advise of the following: How much is required for your deposit? Are you due to have a refund from your current landlord? Yes No If yes, how much and when will you receive this? Date Have you now or in the past received similar assistance through a rent deposit guarantee scheme or anything similar? Yes No If yes, how much and when will you receive this? Date DHP CDHF Form V2.0 September

7 For Deposit schemes only please provide: Landlord NAME & ADDRESS SORT CODE ACCOUNT NUMBER If you need help for rent in advance, please confirm the full contractual rent of the property you are intending to move into. If you need help with removal costs, please tell us how much this will be. Please tell us the date you moved in/intend to move in and why you chose your home? Have you or a family member got any health problems or disabilities? If you incur additional expenses due to health reasons, please state them here. Please tell us why you chose this property? Eg, has it been adapted if you have a disability, or is ground floor accommodation, etc. Have you tried to find other suitable accommodation? Please give details if you have looked for cheaper or smaller properties. If you have had a previous DHP award, what steps have you taken to improve your situation since your last application was granted? Eg, reduced outstanding debts or other outgoings? DHP CDHF Form V2.0 September

8 Which of the following apply to you? You may tick more than one box. You need short term help to move into longer term housing of a good standard of repair. Living in this area means a better chance of retaining or obtaining employment. You have short term problems what you cannot deal with at the moment. You have debt problems. You need help or guidance to find out what other benefits you may be entitled to. Other Please state the reason(s) why you fall into the categories above. Could you afford the rent when you first moved in? Yes No Were you aware of the amount of Housing Benefit that could be paid before you moved in? Has this request for a DHP been made as a result of a Home Options interview? Are you related to your landlord? Yes Yes Yes No No No How much is your rent and how often is it paid? Does your rent include money for any of the following and how much? Meals Heating Lighting Office use only Weekly DHP CDHF Form V2.0 September

9 Hot water Fuel for cooking General counselling and support Emergency alarm systems Cleaning rooms and windows Garage or parking space Nursing or personal care Office use only Weekly If you pay any other charges separate from your rent. How much and what is it for? Paying you direct into an account The safest and easiest way to receive your benefit is direct into your bank, building society or Credit Union account. This avoids the risk of cheques being stolen or delayed in the post. If you do not give us your account details, we will pay your Discretionary Housing Benefit by cheque and you will need an account in your name so you can cash the cheque. If you want us to pay you direct into your account, please tell us about the account you want to use below. Please tell us the name or names the account is in? What is the full name and address of the bank, building society or Credit Union you want us to pay your benefit into? We cannot pay into a Post Office Card account. DHP CDHF Form V2.0 September

10 Account Sort Code Account Number Roll or Reference number (if needed) Signed: Date: PLEASE RETURN THIS FORM TO: Benefit Service PO Box 8267 Birmingham B4 7XF Tel: DHP CDHF Form V2.0 September