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1 Rotherham Metropolitan Borough Council Housing and Council Tax Benefit Section Riverside House Main Street Rotherham S65 1UF Phone: Website: Name and address Reference Housing Benefit and Council Tax Benefit Claim for a Discretionary Housing Payment (DHP) Application form for private tenants and housing association tenants Home Phone Number address Mobile Phone Number Request for Discretionary Housing Payment If you are in receipt of Housing and or Council Tax Benefit you may be able to claim temporary extra help from the Discretionary Housing Payments Scheme. When can these payments be made? Discretionary Housing Payments can be made if: You are already in receipt of Housing and Council Tax Benefit You have unavoidable additional expenses because of special circumstances such as someone being ill or in hospital You are having difficulty paying your rent or council tax while trying to find a cheaper property The rent officer has restricted the amount of rent we can use to calculate your benefit and you have special reasons as to why you need to stay in a particular property. How to apply You will need to download and print this application form, returning it to the address shown at the top of the form, once you have completed it. Please make sure you write your name and national insurance number on every page. We need you to explain your personal circumstances in as much detail as possible and also tell us what may happen if you do not receive extra help. Please make sure you complete each section giving as much detail as you can in relation to the boxes you have ticked. When providing reasons why you need further help, you might include: Any unusual or difficult circumstances due to you or your family's health or any other problems which relate to your housing costs Reasons that are personal to you or your family Why you need to stay in your present home even though it is causing you hardship. Evidence or proof to support your claim but this is not compulsory. 1

2 How much will I get and how are payments made? If you are successful you will receive payments in the same way as your Housing and Council Tax Benefit. There is no fixed rate for a Discretionary Housing Payment. The amount we pay is decided individually for each claim. The amount you are awarded will be based on your circumstances. The maximum we can pay is the difference between the benefit you are already receiving and your council tax liability or eligible rent charge. The amount can also be lower than the difference between the two. How long are Discretionary Housing Payments paid for? If you do receive extra help it will be for a limited period only. Awards are normally paid for a number of weeks to help your current situation. Once your award has ended you may wish to reapply for a new period to be considered. If your circumstances change while you are receiving these payments you must tell us immediately. All information you provide will be treated in confidence and you do not have to provide any details you do not want to. SECTION 1: INFORMATION ABOUT YOU AND YOUR FAMILY Have you or any of your family got health problems or disabilities which mean you have to live at this address? Yes No If Yes, please give their names and use the space below to tell us what the health problems or disabilities are, how long they have had the problems and how this restricts your choice of housing or your ability to pay the shortfall in your rent. 2

3 Do you or any of the people living with you as part of your family have any special circumstances that you would like us to consider when making our decision? Yes No If Yes, please give details below. Have you had a recent change in circumstances which have made it more difficult to meet your rent payments? Yes No If Yes, please give details: 3

4 SECTION 2: ABOUT YOUR ACCOMMODATION Only complete this section if you are in privately rented accommodation. Please provide the reason(s) why you chose this property. Did you consider any other accommodation? Yes No If Yes, please give details below Address looked at Reason(s) why unsuitable If No, can you explain why you did not consider any other properties? Has the property been adapted for a disabled person's needs? Yes No If Yes, please give details below What was your previous address? Why did you move from this address? Did you pay rent at your previous address? Yes No 4

5 SECTION 3: MORE INFORMATION ABOUT YOUR HOUSING COSTS Do you pay rent? Yes No If Yes, please go to the next question If No, please go to Section 4 How much rent do you pay each week? Have you asked your landlord/landlady to accept a less rent? Yes No If Yes, what was their response? If No, please provide your reasons for not doing so Has your landlord asked you to leave the property? Yes No If Yes, please provide the date they asked you to leave, the date they say you have to have left by and confirm whether or not you have been served with a Notice of Eviction. Please tell me what alternative accommodation you would be able to use if you were evicted. 5

6 SECTION 4: INCOME & EXPENDITURE Please enter the amounts you actually spend on the items listed. Where possible please supply proof of your expenditure, for example quarterly bills, catalogue repayment statements, loan agreements. Please note that if you take this information to either Riverside House, Rotherham or any of the Councils Customer Service Centres or District Offices they will be copied free of charge. Income Week/Month Debts Wkly/Monthly Repayment Take home pay Rent arrears Partners take home pay Mortgage arrears State Pension Secured loans Partners State Pension Council Tax arrears Private Pension Water rates arrears Partners Private Pension Gas arrears Pension Credits Electricity arrears Working Tax Credits Fines arrears Child Tax Credits Maintenance arrears Incapacity Benefit Other 1 Income Support Other 2 Jobseekers Allowance Other 3 Child Benefit Other 4 Maintenance/Child Support Other 5 Lodgers/Non dependants Other 6 Disability Living Allowance Attendance Allowance Carers Allowance Employment and Support Allowance Other Total Income Balance Owing Expenses Week/Month Mortgage Travelling expenses Mortgage Endowment School Meals Rent (after benefit deducted) Clothing Council Tax (after benefit ) Childcare Water rates Pocket Money Ground rent/service charges Telephone House Insurance Prescriptions Life Insurance Leisure Repairs Other Gas Other Electricity Total expenses Other fuel Housekeeping TV Licence Maintenance Payments TV Rental Fines 6

7 SECTION 4 CONT'D Capital Please provide your bank and / or building society details below Name of Bank or Building Society Account Number Current balance Please complete the section below if you hold any stocks, shares or National Insurance Certificates. Company Number held / Issue Number SECTION 5: FURTHER DETAILS Please use the space below to provide any further information you feel could help your application. 7

8 SECTION 6: YOUR DECLARATION Please read this declaration carefully before you sign and date it. I understand the following This is my claim for Discretionary Housing Payments If I give information that is incorrect or incomplete, you may take action against me. You may check some of the information with other sources within the Council, rent offices and other councils. You may use any 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 information to other government organisations, if the law allows this. I know that I must notify you immediately about any changes in my circumstances which may affect my claim. I declare the information given on this form is correct and complete. Signature: Date: 8

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