APPLICATION FOR HOUSING BENEFIT AND COUNCIL TAX BENEFIT

Transcription

1 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 1 APPLICATION FOR HOUSING BENEFIT AND COUNCIL TAX BENEFIT The information hed on thi form wi be hed on computer where it i ubject to the Data Protection Act. Name Date Received Stamp Addre Date Sent: Pot Code Reference. ABOUT THIS FORM Thi form give u the information we need to cacuate how much benefit you may be entited to. Peae read the note and quetion carefuy and anwer every quetion in back ink. If you do not anwer every quetion, we wi need to contact you and may need to return the form to you. Thi wi deay your caim. PROOF TO SUPPORT YOUR CLAIM We wi need to ee Two Origina document to confirm your identity. We wi ao need origina document to confirm your income, capita and rent. RETURNING THE FORM You can pot your appication form and document to the addre hown on the back of thi form. Your document wi be copied and poted back to you a oon a poibe. If you are houebound we can arrange for omeone to viit you at your home to hep you. START OF BENEFIT ENTITLEMENT Your benefit wi normay tart from the Monday after you firt contacted u a ong a your form i returned within one month of the firt contact date. If your form i received more than one month after you firt contacted u, your benefit wi not normay tart unti the Monday after the form i received. If you do not have a the neceary proof to upport your caim, peae return the form traight away with a note to expain which document wi be ent ater. ENQUIRIES If you have any querie about thi form, peae contact the Benefit Office at the addre hown on the back of thi form. If you phone u we wi be happy to return your ca. 1

2 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 2 GUIDANCE NOTES SECTION 1 SECTION 1 i about your home. You mut fi in thi ection. If you own your home you do not need to anwer quetion about your tenancy or your rent. HOUSING BENEFIT (HB): (ometime caed rent rebate or rent aowance) Anyone who ha to pay rent for their home can caim. It doe not matter whether your andord i a private individua, a Houing Aociation, a etting agency or the oca Counci. You cannot normay caim Houing Benefit if you ive with a coe reative. COUNCIL TAX BENEFIT (CTB): If you are iabe to pay Counci Tax, you may be abe to reduce your bi in one of two way:- If you are on a ow income, you may caim Counci Tax Benefit in your own right OR If you do not quaify for Counci Tax Benefit in your own right becaue your income i too high, you may ti be abe to caim if other peron (not your partner, joint owner, joint tenant or omeone who pay you rent) haring your home have ow income. Thi i caed Second Adut Rebate. Coupe are not normay eigibe to caim Second Adut Rebate If you wih to caim Houing Benefit and/or Counci Tax Benefit on the bai of your own circumtance, you houd compete a ection of thi form. If you wih to ony caim Second Adut Rebate on the bai of the circumtance of another adut (or adut) iving in your houehod, you need ony compete ection 1, 2, 3, 5 and 6 and then ign the decaration at the end of ection 17. If you are not ure, you houd compete the whoe form and we wi work out the better option for you If you hare paying the rent with omeone who i not your partner you wi ony receive benefit on your hare of the rent. We ue the word partner to mean a peron you are married to, a peron you ive with a if you were married to them, a civi partner or a peron you ive with a if you were civi partner. 2

3 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 3 1. YOUR HOME The addre you are caiming for Pot Code Daytime Teephone Number e-mai addre Are you a Counci Tenant? Do you own your home? Do you jointy own your home with omeone who i not your partner? Do you wih to caim 2nd Adut Rebate ony? Do you pay rent to a private andord or Houing Aociation? Peae tate Ye or Peae tate Ye or Peae tate Ye or Peae tate Ye or Peae tate Ye or If you pay rent to a private andord/houing Aociation you wi ao need to compete ection 13 and 14 When did you move in or expect to move in? When did your tenancy tart? If you did not move in traight away, peae give the reaon for the deay. Have you ever owned the home you are caiming for? Peae tate Ye or If Ye, peae give detai Peae give your previou addre Pot Code What wa your tatu at thi addre (e.g. owner, tenant, with reative etc.) Have you caimed HB/CTB in the at 52 week? Have you received HB/CTB for another property? If Ye, peae give the at addre you caimed at If Ye, peae ao give the date you at caimed Doe anyone hare the rent payment with you who i not your partner? If Ye, how many peope hare the rent? Peae tate Ye or Peae tate Ye or Pot Code Peae tate Ye or 3

4 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 4 GUIDANCE NOTES SECTION 2 SECTION 2 i about youref. You mut fi in thi ection. We cannot grant benefit if you have not given your Nationa Inurance Number and provided ome evidence to how that your Nationa Inurance Number i correct. If you cannot provide uitabe evidence we wi have to write to the Department for Work and Penion to get confirmation. Thi wi deay your caim. You houd provide two item from the foowing it, one of which mut how your Nationa Inurance Number. Bank tatement (e than 4 week od) Benefit Award etter Utiity bi (paid in your name for the at quarter) Paport (current and vaid) Wage ip from your current empoyer Birth Certificate Certificate of empoyment in HM Force Driving Licence Certificate of empoyment in the Merchant Navy Credit Card Statement Divorce/Annument paper Marriage Certificate Life aurance/inurance poicie Medica card Nationa Inurance Number card UK reidence permit Identity card iued by an EC/EEA member tate Home Office Standard Acknowedgement Letter (SAL 1 or 2) Letter from oicitor/ocia worker/probation officer/inand Revenue n-uk paport hoder houd uppy their paport to how that they have the right to caim benefit. Any document you uppy mut be origina photocopie are not acceptabe. If you are in receipt of Income Support, Job Seeker Aowance, Penion Credit or Empoyment Support Aowance and you have changed your addre, you mut te the Department for Work and Penion, Job Centre Pu or the Penion Service traight away. If you are a tudent we may write to you to requet further information. If omeone receive, or ha made a caim for, Carer Aowance for ooking after you, or you are regitered bind you may receive extra hep with your rent or counci tax. If you are in hopita your benefit entitement may be affected. If you have come to ive in the UK, Repubic of Ireand, Channe Iand or the Ie of Man in the at 2 year, you may not be abe to receive hep with your rent. We may need to write to you or we may need to approach the Home Office for further information. If you are regitered with the Home Office Worker Regitration Scheme you wi ao need to provide your Worker Regitration Certificate. 4

5 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 5 2. YOURSELF Tite Surname Firt Name Mr/Mr/Mi/M Any other name ued (if appicabe) Date of Birth Nationa Inurance. Are you receiving Income Support? Peae tate Ye or Are you receiving Job Seeker Aowance (Income Baed)? Peae tate Ye or Are you receiving Empoyment Support Aowance (Income Reated)? Peae tate Ye or Are you receiving Guarantee Penion Credit? Peae tate Ye or Have you made a caim for Income Support, Job Seeker Aowance, Empoyment Support Aowance or Penion Credit? Peae tate Ye or Are you a Student? Peae tate Ye or If, Ye peae provide evidence of your coure Are you regitered bind? Peae tate Ye or Ha anyone ever received or made a caim for Carer Aowance for ooking after you? Peae tate Ye or If Ye, peae give the name of thi peron: Are you currenty in hopita? Peae tate Ye or If Ye, peae give date of admiion: What i your nationaity? Are you regitered with the Home Office Worker Regitration Scheme? Peae tate Ye or If Ye, peae provide your Worker Regitration Certificate Have you come to ive in the UK, Repubic of Ireand, Channe Iand or the Ie of Man in the at 2 year? Peae tate Ye or If Ye, when did you enter the UK Are you eigibe to caim benefit in the UK? Peae tate Ye or (for n-uk paport hoder ee via entry condition in your paport) 5

6 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 6 GUIDANCE NOTES SECTION 3 SECTION 3 i about your partner. You mut fi in thi ection if you have a partner you ive with. We ue the word partner to mean a peron you are married to, a peron you ive with a if you were married to them, a civi partner or a peron you ive with a if you were civi partner. We cannot grant benefit if your partner doe not have a Nationa Inurance Number. If your partner doe not have a Nationa Inurance Number, we can appy for one and wi need to ak further detai of your partner identity. Thi wi deay your caim. Peae end proof of your partner Nationa Inurance Number If your partner i in receipt of Income Support, Job Seeker Aowance, Penion Credit or Empoyment Support Aowance and ha changed their addre, they mut te the Department for Work and Penion, Job Centre Pu or the Penion Service traight away. If your partner i a tudent we may write to you to requet further information. If omeone receive, or ha made a caim for, Carer Aowance for ooking after your partner, or your partner i regitered bind you may receive extra hep with your rent or counci tax. If your partner i in hopita your benefit entitement may be affected Any document you uppy mut be origina photocopie are not acceptabe. 6

7 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 7 3. YOUR PARTNER Do you have a partner who ive with you? Peae tate Ye or If, peae go to ection 4. If Ye, peae compete thi ection Peae tate date they moved in Tite Surname Firt Name Mr/Mr/Mi/M Any other name ued (if appicabe) Date of Birth Nationa Inurance. Are they receiving Income Support? Peae tate Ye or Are they receiving Job Seeker Aowance (Income Baed)? Peae tate Ye or Are they receiving Empoyment Support Aowance (Income Reated)? Peae tate Ye or Are they receiving Guarantee Penion Credit? Peae tate Ye or Have they made a caim for Income Support, Job Seeker Aowance, Empoyment Support Aowance or Penion Credit? Peae tate Ye or Are they a Student? Peae tate Ye or If, Ye peae provide evidence of their coure Are they regitered bind? Peae tate Ye or Are they currenty in hopita? Peae tate Ye or If Ye, peae give date of admiion: Ha anyone ever received or made a caim for Carer Aowance for ooking after them? Peae tate Ye or If Ye, peae give the name of thi peron: 7

8 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 8 GUIDANCE NOTES SECTION 4 SECTION 4 i about your chidren. Thi Section i ony to be ued for chidren who are iving with you, and that you or your partner get Chid Benefit for. Thi woud uuay be your, or your partner, own chidren who are ti at choo or in further education and under 20. If your chid i receiving Diabiity Living Aowance you may be abe to get more hep with your rent or counci tax. Peae end proof of thi with your caim. If your chid i regitered bind you may be abe to get more hep with your rent or counci tax. Peae end the regitration document with your caim. If you pay for chidcare, we may be abe to diregard ome or a of the charge againt your earning. Peae end receipt to how the amount of chidcare that you pay. Adut chidren, or chidren who are in higher education (e.g. Univerity), who ti ive with you houd be incuded in Section 5. Foter chidren houd be incuded in Section 6. Any document you uppy mut be origina photocopie are not acceptabe. 8

9 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 9 4. YOUR CHILDREN Do you or your partner receive Chid Benefit Peae tate Ye or for any chidren who ive with you? If Ye, peae compete thi ection for each of your chidren. If, peae go to Section 5. If you have more than 3 chidren, peae give their detai at the bottom of thi page Surname 1t Chid 2nd Chid 3rd Chid Other name Date of Birth What i their reationhip to you? Are they mae or femae? Do they receive Diabiity Living Aowance? Ye Ye Ye Are they regitered bind? Ye Ye Ye Do you pay chidcare? Ye Ye Ye If Ye, peae give the name and addre of the chidminder/ nurery/paycheme What i their Loca Authority regitration number? What i the weeky cot of chidcare for each chid? Doe the amount you pay vary at any time? (eg choo hoiday) Ye Ye Ye Peae give detai of additiona chidren or variation in chidcare cot beow 9

10 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 10 GUIDANCE NOTES SECTION 5 SECTION 5 i about other peope who ive in your home who are caed a non-dependant. A non-dependant i omeone who ive with you, but who doe not pay any rent for the property. They may have an informa arrangement to give you an agreed um for their keep. Peope in thi group may incude: grown-up chidren, parent, other reative or friend. A non-dependant i different from a boarder or a ub-tenant or a joint tenant. Peae ee Section 6 for the definition of boarder, ub-tenant and joint tenant We wi need to ee proof of the income of a non-dependant in your home. Peae note that non-dependant receiving Income Support (IS), Job Seeker Aowance (income baed) (JSA(IB)), Penion Credit (PC) or Empoyment Support Aowance (ESA) wi affect your benefit in different way. Peae end proof of any of thee income if any of your non-dependant receive them. Peae ao end proof of the tudent coure if any of your non-dependant are tudent. You mut et u know if any of your non-dependant ive together a a coupe, or if they are in hopita or prion a thi coud affect the amount of benefit you receive. Any document you uppy mut be origina photocopie are not acceptabe. 10

11 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page NON-DEPENDANTS WHO LIVE WITH YOU Do you have any non-dependant iving with you? Peae tate Ye or If, peae go to Section 6. If Ye, peae compete thi ection. 1t Peron 2nd Peron 3rd Peron Surname Other name Date of Birth Nationa Inurance. Their reationhip to you Date they moved in Do they receive IS, JSA(IB), PC or ESA? Ye Ye Ye Do they work? Ye Ye Ye If Ye, how many hour per week? What are their earning per week before deduction Do they have any other income? Ye Ye Ye If Ye, peae give detai, incuding the amount. Do they get Diabiity Living Aowance or Attendance Aowance? Ye Ye Ye If Ye, how much do they get each week? Do they provide care for anyone in your home? Ye Ye Ye If Ye, who do they provide the care for? What i their reationhip to thi peron? Are they a Student? Ye Ye Ye Are they Severey Mentay Impaired? Ye Ye Ye Are they in prion or in hopita? Ye Ye Ye If Ye, peae tate which If Ye, peae give the date that they went into prion or hopita Are any of thee peope married or civi partner or iving together a if they were? Ye Ye Ye If Ye, peae ay who: i the partner of If you have more than 3 non-dependant peae provide their detai at the end of Section 6 and put the number here 11

12 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 12 GUIDANCE NOTES SECTION 6 SECTION 6 i about anyone ee who ive in your home. A boarder i omeone who ive with you and who ha a commercia agreement with you to pay for their accommodation and for mea which you provide for them. Boarder are often known a odger A ub-tenant i omeone who ha a commercia agreement with you to pay for their accommodation, but whoe rent doe not cover any mea. We wi need to ee evidence of the amount that you receive from any boarder and ub-tenant in your home. A joint-owner i omeone (other than your partner) who jointy own the property you ive in. A joint-tenant i omeone (other than your partner) who i jointy reponibe with you for paying the rent for the property you ive in. 12

13 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page ANYONE ELSE WHO LIVES IN YOUR HOME Do you have any joint-owner, joint-tenant, ub-tenant or boarder iving with you? Peae tate Ye or If, peae go to Section 7. If Ye, peae compete thi ection. Surname Other name Date of Birth (if known) Nationa Inurance. (if known) Their reationhip to you Date they moved in 1t Peron 2nd Peron 3rd Peron Are they a joint-tenant or joint-owner? Ye Ye Ye You do not have to compete the ret of thi ection for joint-tenant or joint-owner Do they pay you any rent? Ye Ye Ye If Ye, how much and how often? per per per Doe their rent incude payment for mea? Ye Ye Ye Doe their rent incude payment for heating/hot water? Ye Ye Ye Detai of any additiona non-dependant not hown in Section 5 Detai of anyone ee not hown above 13

14 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 14 GUIDANCE NOTES SECTIONS 7 & 8 SECTION 7 i about your paid empoyment. SECTION 8 i about ef-empoyment. If you or your partner are working for an empoyer we need to know how much you receive. You mut provide proof of your earning. You mut te u how often you are paid, (eg weeky, monthy, 4 weeky) If you are paid weeky we wi need your at 5 pay ip. If you are paid monthy or 4 weeky we wi need your at 2 pay ip. If you cannot provide payip or you ony receive handwritten payip (which are not acceptabe), then peae ak your empoyer to compete the Certificate of Earning at the back of thi appication. You mut te u how you are paid, e.g. by cah, direct to your bank/buiding ociety account or by cheque. If you have more than one empoyer you houd give detai of each job on page 16. If you or your partner are ef empoyed, you houd end u propery prepared account. If you have not been ef-empoyed for very ong, or if for ome reaon you cannot provide accurate and compete account, you houd compete part A and B of ection 8. Peae provide the reaon on page 16 a to why you do not have trading account. If you are a Director/Secretary of a Regitered Limited Company you wi need to compete Section 7 or Section 8 a appicabe to you. 14

15 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page EMPLOYMENT Are you or your partner in paid empoyment? Are you or your partner adirector/secretary of a Regitered Limited Company? Are you or your partner ef-empoyed? Peae tate Ye or Peae tate Ye or Peae tate Ye or If Ye to any of the above, peae continue with ection 7 and 8 a appicabe. If, peae give date at worked and go to Section 9. You Your Partner Job Tite Empoyer name &addre You Your Partner Empoyer teephone no. Payro number Date tarted work Date due to end (if known) Average weeky hour worked Date of at pay rie Date of next pay rie (if known) How are you paid? How much are you paid? per per Do you receive a bonu? Ye Ye If Ye, how much and how often? per per Do you receive tip? Ye Ye If Ye, how much and how often? Do you receive Statutory Sick Pay? If Ye, how much and how often? Do you receive Statutory Maternity/Paternity/ Adoption Pay? If Ye, how much and how often? Do you have more than 1 empoyer? If Ye, how many? per Ye per Ye per Ye per Ye per Ye per Ye Peae give detai of additiona empoyer on the back of thi page 15

16 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:47 Page 16 Additiona Information Regarding Empoyment 16

17 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page SELF EMPLOYMENT Nature of Buine Buine name and addre You Your Partner Buine te no. Date buine tarted Average weeky hour worked Are you a ub-contractor Ye Ye If you are unabe to provide proper trading account, peae continue beow Period that you are giving figure for From To A. INCOME Sae (or Taking) Other income of the buine, peae pecify GROSS INCOME = B. EXPENSES (ony incude amount reating oey to buine) Purchae of tock/uppie Wage paid to wife/huband Wage paid to other Rent for buine ue Rate Heating Lighting Motor expene - Petro - Inurance From - Road Tax From To To - Repair and maintenance Advertiing Printing & tationery Potage Teephone Inurance Bank charge Interet on payment on buine oan Loan to repair/repace exiting buine aet VAT Bad Debt Drawing Other (peae pecify) GROSS EXPENSES = 17

18 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 18 GUIDANCE NOTES SECTION 9 SECTION 9 i about other income you have, incuding State benefit and penion. You mut compete thi ection, even if you receive the benefit/penion for omeone ee. For each income ited peae indicate in the reevant box the amount you receive before deduction and how often it i received e.g. weeky, monthy, 4 weeky, etc. If you do not receive one of the income ited write ni in each reevant box. If you are waiting for a deciion on any of the income ited peae write appied in the reevant box. The type of proof required for each income you receive i ited in the right hand box. Peae remember that any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you do not have your notification etter from the Department for Work and Penion, Job Centre Pu or the Penion Service you can ak for a dupicate or we may be abe to obtain the information for you. If you have made a caim for carer aowance but were not entited, peae et u have your notification etter. 18

19 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page BENEFITS, PENSIONS AND OTHER INCOME Type of income You Partner Wky/Mthy/ Proof needed 4Wky etc Income Support Empoyment Support Aowance Job Seeker Aowance Chid Benefit Working Tax Credit Chid Tax Credit State Retirement/Widow Penion Penion Credit Widowed Parent Aowance/ Bereavement Aowance Your notification etter Penion from former empoyer (1) Penion from former empoyer (2) Incapacity Benefit - Short term ower rate - Short term higher rate - Long term rate Attendance Aowance Diabiity Living Aowance - Care component - Mobiity component Maternity Aowance Carer Aowance Indutria Injurie Benefit/Reduced Earning Aowance Severe Diabiity Aowance War Diabement Penion War Widow Penion Maintenance payment - for youref - for your chidren Lat 2 pay ip Your notification etter Court order or CSA etter Charitabe or Vountary Payment Any other income (peae tate ource) Any reevant evidence 19

20 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 20 GUIDANCE NOTES SECTION 10 SECTION 10 i about your aving, invetment and bank account. If you do not have any aving, invetment, hare, bond or bank account peae write ni in each reevant box. If you have a joint account you may ue either the you or your partner box. If you or your partner have bank or buiding ociety account peae give the name of the bank or buiding ociety and the current baance of your and your partner account incuding current account. You mut provide either your bank/buiding ociety book or the atet fu tatement covering a period of at eat 2 month for every account. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you or your partner have a Pot Office account peae give the current baance of your or your partner account(). You mut provide your or your partner Pot Office account book and/or card account tatement. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you or your partner have any tock or hare incuding thoe you may have been given by a company or bank peae give the number of hare hed and the company or bank name. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you or your partner have any Nationa Saving Certificate or Premium Bond we need to know the number of unit you have and any reevant iue number. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you or your partner have any Income Bond, ISA and PEP peae give the current vaue of thee invetment a hown on your atet tatement. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you have received a payment a a Far Eatern prioner of war or for perona injury, peae te u. We need to know o that we can diregard thee payment from any other capita you have. You houd ao te u if anyone in your houehod ha received payment a a ufferer of Variant Creutzfedt- Jakob dieae (VCJD). Thee payment are ao diregarded. 20

21 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page SAVINGS, INVESTMENTS & CAPITAL How many bank or buiding ociety account do you have? How many bank or buiding ociety account doe your partner have? You Your Partner Bank/Buiding Society Name Account Type Account baance Account Type Account baance Do you or your partner have any other capita, aving or invetment? Peae tate Ye or If, peae go to Section 11. If Ye, peae continue beow. Pot Office Account baance Account baance Share Company Name. of hare. of hare Premium Bond. hed Vaue. hed Vaue Nationa Saving Certificate. of unit/vaue Iue.. of unit/vaue Iue. Current vaue Current vaue Income Bond Current vaue Current vaue ISA Current vaue Current vaue PEP Amount Amount Cah at home Have you received one of the foowing payment Variant Creutzfedt-Jakob dieae (VCJD), Far Eatern Prioner of War, Perona Injury Compenation? Peae tate Ye or If Ye, peae tate which and how much If you or your partner have any capita, aving or invetment not hown above, peae tick thi box and give detai on a eparate heet. 21

22 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 22 GUIDANCE NOTES SECTION 11 SECTION 11 i about any and or property which you or your partner own in addition to the property you currenty ive in. If the additiona property i et to a reative we wi need to ee the tenancy agreement and rent receipt. We wi ao need to know the age of the reative and whether or not they are incapacitated. If the additiona property i occupied by an ex partner who i a one parent we wi need to ee the Chid benefit notification etter. Ony origina document are acceptabe, not photocopie. We wi return a document. Otherwie the market vaue of the property and any and you own may be taken into account. We may need to end you a Vauation of Property/Land form to fi in. SECTION 12 SECTION 12 i about the payment you make ometime caed outgoing. If you contribute to a penion cheme other than one with your empoyer peae provide the poicy and proof of payment being made. If you are paying to upport a chid who i at coege or univerity peae end detai of their coure, the term date and the grant aement form. 22

23 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page ADDITIONAL PROPERTY OR LAND Do you or your partner own other property or and? Peae tate Ye or If, peae go to ection 12. If Ye, peae give the addre of the property or the ocation of the and Market Vaue of the property or and? Vaue of outtanding mortgage? (if any) I the property et to a reative who i aged 60 or over or who i incapacitated? Doe an ex partner ive in the property? Peae tate Ye or Peae tate Ye or If Ye, to either of the above, how much rent do you receive? How often received? I the property for ae? Peae tate weeky/monthy/4 weeky Peae tate Ye or If Ye, peae give fu detai on a eparate heet 12. PAYMENTS YOU MAKE Do you or your partner make payment into a private penion cheme or hep upport chidren at coege/univerity? Peae tate Ye or If, peae go to ection 13. If Ye, peae compete thi ection. Private Penion Scheme Youref Partner Amount of contribution How often paid? Peae tate weeky/monthy/4 weeky Hep to upport chidren at coege or univerity Amount of contribution Youref Partner How often paid? Peae tate weeky/monthy/4 weeky 23

24 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 24 GUIDANCE NOTES SECTION 13 SECTION 13 i about your tenancy and the rent you pay. You mut compete thi ection if you have a iabiity to pay rent to a private andord or Houing Aociation. You mut te u who your andord i and their addre. If you do not pay rent to your andord but omeone ee, e.g. an agent, you mut te u the agent name and addre a we. If a fair rent ha been regitered on your property you wi need to uppy a copy of the regitration document. If you have been ubject to a Care Order or have been ooked after by Socia Service we may need to contact you about thi. We wi need to ee proof of the amount of rent you pay and the ervice incuded (ie Counci Tax, Water Rate, Heating etc) - your tenancy agreement, rent receipt, rent book, etter from your andord or a etter from the agent. It mut incude the foowing information. the name and addre of your andord; the name and addre of the Managing agent if appropriate; the amount you pay; what i incuded in your rent for exampe, mea, eectricity; how often you pay the rent for exampe, 4 weeky, monthy. Any document you uppy mut be origina photocopie are not acceptabe. We wi return a document. If you do not have thi information you mut obtain a etter from your andord or ak your andord to compete the Landord Statement at the back of thi appication. 24

25 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page TENANCY AND RENT DETAILS You houd ony compete Section 13 and 14 if you pay rent to a private andord or Houing Aociation. When did your tenancy tart at your current addre? Landord name Landord buine addre and teephone number If the andord ha an agent, you ao need to te u Agent name Agent addre and teephone number Are you, or your partner, or any of your chidren reated to the andord or the andord partner? Are you, or your partner, or any of your chidren reated to the agent? If Ye, who i reated, and what i the reationhip? Do you rent your home from your, or your partner, former partner? Have you igned a tenancy agreement? What kind of tenancy i it? Ha your rent been regitered by the Rent Officer a a fair rent? Are you, your partner, or any of your chidren a beneficiary of a Wi which ha not yet been etted? If Ye, peae give detai, and et u ee the Wi Do you occupy your home a a condition of your or your partner empoyment? Have you ever been the ubject of a care order or had accommodation provided by Socia Service? Ye Ye Ye Ye Ye Ye Ye Ye 25

26 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 26 GUIDANCE NOTES SECTION 13 TENANCY AND RENT DETAILS CONTINUED Houing Benefit for private ector tenant i normay paid under Loca Houing Aowance (LHA) rue. The rent we ue to cacuate benefit wi depend on the number of peope in your houehod and their age. Peae contact u or ook on our webite to ee how the ize criteria i cacuated. Loca Houing Aowance rate are dipayed in our office and can ao be found on our webite. Some accommodation type are exempt from thi cheme, i.e. Counci and Houing Aociation tenant, hote, houeboat, caravan, ite pitche, accommodation where a ubtantia part of the rent cover board &attendance (uch a Hote) and pre 15 January 1989 tenancie. Leafet with more information about LHA rue can be found in our office or on our webite. Your andord houd have made cear to you whether or not any ervice are incuded within your rent, and you houd give a much detai here a you can. We ony need thi information if you are a tenant of a Houing Aociation, have a regitered rent or are exempt from Loca Houing Aowance. If in doubt it i bet to compete the information. Benefit paid under Loca Houing Aowance wi normay be paid direct to you and it wi be your reponibiity to pay your rent to your andord. You cannot impy chooe to have your benefit paid direct to your andord. LHA wi normay be paid direct into a bank account. Thi mean that you wi need to open abank account if you do not have one aready. You can then arrange for your bank or buiding ociety to pay your rent to your andord automaticay. One way of doing thi i caed a tanding order. If you need to find out more information about opening a bank account, peae contact u. 26

27 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page TENANCY AND RENT DETAILS - continued You houd ony compete Section 13 and 14 if you pay rent to aprivate andord or Houing Aociation. How much rent doe your andord charge you? I thi every? Day Week Fortnight 4 Week Caendar Month Quarter Who do you pay the rent to? Do you have any rent-free week? Ye If Ye, when are they? Are mea incuded in your rent? Ye Which one? Breakfat? Ye Lunch? Ye Evening Mea? Ye Are you in arrear with your rent? Ye If you have ticked Ye, tate how much If you know in advance when your rent i due to be increaed, peae enter the date in the box. Doe the rent you pay incude any of thee charge? If Ye, peae te u how much per week (if you know). We may have to write to you or your andord for further detai. Water rate Counci Tax Hot Water Laundry Garage Ye Lighting (your room) Ye Ye Fue for Cooking Ye Ye Heating (your room) Ye Ye Ceaning Ye Ye How your Houing Benefit wi be paid Benefit paid under Loca Houing Aowance (LHA) Your benefit wi be paid directy to you une you fee thi may caue you difficuty. Contact u for a Direct Payment to Landord form if you think you may have reaon for u to pay your andord. Houing Aociation and Tenant exempt from (LHA) You can have payment made to you or to your andord if you prefer. Method of payment A payment wi be made directy to a bank account. Contact u if you need hep to open a bank account. Do you want your Houing Benefit to be paid to you? Ye or to your andord? Ye If you pay rent to aprivate andord, and you have aked u to pay your andord, both you and your andord wi need to ign the Direct Payment to Landord heet at the end of thi form. Name of the Bank or Buiding Society that you want u to pay benefit into Account Hoder Name Branch Account. Sort Code 27

28 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 28 GUIDANCE NOTES SECTION 14 SECTION 14 i about your home. You mut te u how many room there are in the whoe of the property and which room they are. You mut ao te u how many of thee room are for your oe ue and which room they are. You ao need to te u if any room are hared with other peope who ive in the property. Once we receive your form we wi know if we mut refer your rent to the Rent Officer who i an independent Government Vauer who, for ome caim, decide how much your rent houd be. 28

29 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page YOUR HOME You houd ony compete Section 13 and 14 if you pay rent to aprivate andord or Houing Aociation. Peae tick box that bet decribe your home Houe Maionette Bungaow Peae te u the number of each type of room in your home, and who ue them Living room How many in the whoe houe or fat How many are ony ued by you and your famiy How many room do you hare with other peope Converted Fat Fat over hop Purpoe Buit Fat Studio Fat Bedit Room in a houe or hote Other (peae give detai - we may need to write to you) Bedroom Bedit room Kitchen Bathroom Toiet Other room (peae pecify) How many foor are there in the whoe buiding? Which foor i your home on? I the property you ive in Detached? Semi-detached? Terraced? If you rent a room, peae te u the room number 2nd Foor 1t Foor Ground Foor Baement Other (peae pecify) Where i your room? (tick one box ony) At the front of the property? At the back of the property? Do you hare your room with anyone? If ye, who with? Doe your andord ive in the property? Ye I there centra heating in your home? Ye If neceary, may we contact your andord or agent to confirm or dicu the rent or tenancy detai? Ye If, what are your reaon for not wanting u to contact them? Do you have ue of a garage? Ye Do you have ue of a parking pace? Ye I the garage or parking pace optiona? Ye Do you have ue of a garden? Ye I your accommodation: Fuy Furnihed? Party Furnihed? Unfurnihed? 29

30 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 30 GUIDANCE NOTES SECTION 15 SECTION 15 i a reminder to check the form through carefuy before you end it to u. If you do not have a the neceary document to end in with your caim, peae end the form in anyway and et u know which document wi foow. If you deay in ending the form, you may oe benefit which you may be entited to. SECTION 16 SECTION 16 i about Backdating of benefit When can benefit be backdated? Houing Benefit and/or Counci Tax Benefit i normay awarded from the Monday after the day you firt contacted u about caiming benefit. You may fee that you houd have had benefit before. The Law ay that, in certain circumtance, we can backdate benefit for a maximum period of 6 month, but ony IF you can prove you had a good reaon why you did not appy ooner. What i a good reaon? Some exampe are:- Death of a coe reative Being in hopita or eriouy i (you mut provide proof e.g. Doctor etter, Sickne Certificate) Being wrongy advied by a peron who houd have known better e.g. CAB, Socia Worker or DWP Staff Language difficutie However, it i not a good reaon impy not appying. 30

31 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page APPLICATION CHECKLIST Have you provided the foowing detai and encoure? Your fu name and addre in the box provided. Origina document ony for Competed a ection of the form Peae tick box Proof of your identity (new appicant ony) Sef Empoyed Account Proof of Earning (Wage Sip or Certificate of Earning) Proof of other income Current account tatement for the at 2 month Proof of aving, capita & invetment Proof of any reevant outgoing payment (ee Part 12) Tenancy detai and proof of rent Any other proof reevant to your caim 16. BACKDATING I wih to caim backdated Houing Benefit/Counci Tax Benefit For the period from to My name i My preent addre i The reaon why I did not caim earier i: If you need more pace peae attach a eparate heet 31

32 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 32 HOW WE COLLECT AND USE INFORMATION ABOUT YOU The Counci coect information for Houing Benefit and Counci Tax Benefit purpoe, but it may be ued for any of the Counci purpoe. We may check information that you provide, or that a third party provide about you, with other information we hod. We may ao get information about you from certain third partie, or give information to them to check the accuracy of information, to prevent or detect crime, or to protect pubic fund in other way a permitted by aw. Thee third partie incude government department and oca authoritie. We wi not dicoe information about you to anyone outide the Counci une the aw permit u to. The Counci i regitered under the Data Protection Act 1998 for thee purpoe and i the Data Controer. If you want to know more about what information we have about you, or the way we ue thi information, peae write to the Counci' Data Protection Officer at the addre hown on the front of thi form. The Counci reerve the right to make a charge for thi ervice. Peae ak for detai. CHANGES IN YOUR CIRCUMSTANCES We ue the information you have given u on thi form to ae your caim for benefit. You MUST te u traight away, in writing, about anything that change and provide origina proof of the change(). Thee are ome exampe of the change you mut report You top receiving Income Support, Job Seeker Aowance, Empoyment Support Aowance or Penion Credit Your Working Tax Credit or Chid Tax Credit change You move (even if you ony move to a different room or fat within the ame property) A chid eave choo or eave home or you have a baby Your chid tart to be cared for, or top being cared for, by a regitered chidminder, or nurery or paygroup Someone move into or out of your home (incuding boarder and ub-tenant) Your income, or the income of anyone iving with you, goe up or down You or anyone iving with you become a tudent, or take up a Government Training Scheme You or anyone iving with you goe into hopita or a nuring home, or goe into prion (even if thi i on remand) You or anyone iving with you get a job, or change their job, or become unempoyed You or anyone iving with you take a econd job You return to work after a period of ine where you have been receiving benefit You or anyone iving with you ha a change in capita or aving (thi doe not appy to peope receiving Income Support, Job Seeker Aowance (Income Baed), Penion Credit (Guarantee Credit) or Empoyment Support Aowance (Income Reated) - you houd notify the DWP) Your rent change une you are a Counci Tenant You receive a deciion from the Home Office Someone tart to receive Carer Aowance for ooking after you or your partner If you change the bank account that we are paying your Houing Benefit into. Anything at a which i different from what you have tod u on thi caim form. You mut te u about thee change in writing. If you don t te u about the change, you may oe money you are entited to, or we may pay you too much benefit which we can ak you to repay. If you re not ure about whether or not you need to te u about a change - te u anyway. 32

33 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page DECLARATION Peae read the Decaration very carefuy before you ign and date it. If you have a partner, he or he mut ign it a we. If you do not ign it we wi have to end the form back to you and thi wi deay your caim. Where the decaration ay "I" or "me" or "my" thi refer to both the caimant and hi/her partner. The Counci can proecute you if you give fae information, or if you provide fae or atered document with your caim, or if you withhod information (incuding achange in your circumtance). Peae tick each box to confirm that you have read and undertand the decaration. Thi i my caim for Houing Benefit, or Counci Tax Benefit, or both. I wi te you if any of the detai on any etter you end me are incorrect. The information I have given i true and compete. You can check any information on thi form. Thi incude ending a Certificate of Earning direct to my empoyer if neceary. I am not caiming Houing Benefit or Counci Tax Benefit for any other addre. I undertand that you may contact government department (for exampe the Department for Work and Penion or the Home Office) or other oca authority office to check the information I have given on the form and to get other information. I undertand that if I do not provide a Nationa Inurance Number, my caim wi not normay be deat with. I wi write to you traight away if there are any change in my circumtance, o that you can work out my benefit again. If Ido not, and Iget too much benefit or dicount, the Counci can ak me to pay it back, and may proecute me. Signature of peron caiming Date Partner ignature Date Form fied in by omeone other than the peron caiming Peae te u why you are fiing in thi form for omeone ee Name of the peron who fied in the form Signature of peron Date Reationhip to the peron caiming If you wih to act a the perona repreentative of the peron caiming benefit in the future, peae contact u and ak for an appointee form. Peae return thi form to: Revenue & Benefit Department, PO Box 505, Oakand Road, Hayward Heath, Wet Suex RH16 1AQ 33

34 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 34 Peae Ue Thi Page To Give U Any Additiona Information You Think May Be Reevant To Your Caim 34

35 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page EMPLOYER S CERTIFICATE OF EARNINGS PRIVATE AND CONFIDENTIAL Counci Tax Benefit/Houing Benefit PART 1 - To be competed by caimant Name and addre Occupation Payro number I authorie my empoyer to compete thi form and return it to the Counci Signed Date Peae now tear out thi page and hand it to your empoyer Part 2 - To be competed by empoyer I woud be gratefu if you coud ait your empoyee by providing the information requeted beow and returning it to the addre hown overeaf. Peae give etimated figure if the above-named ha been empoyed by you for e than the reevant period. Nationa Inurance (N.I.) Number Tax Code Earning: Peae give the at 5 week / 2 month / 3 fortnight pay 1 Wk/Month* ended 2 Wk/Month* ended 3 Week ended 4 Week ended 5 Week ended Period Covered Baic Gro pay exc. Overtime, etc Commiion, Overtime, etc Income tax Nationa Inurance Penion Cont made by Empoyee Net Pay * Peae tick box if payment i made every four week * Peae tick box where etimated figure are given Gro pay date for the current tax year a at Week/Month. Income Tax to date Nationa Inurance to date Private Penion to date Average number of hour per week 35

36 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page EMPLOYER S CERTIFICATE OF EARNINGS Part 2 - Continued Method of payment (eg cah, cheque, direct to bank account) Doe your empoyee receive a bonu? Ye If, Ye how much per In order that the Counci may determine how far thee week or month repreent norma average earning, peae give detai of any pecia fuctuation affecting gro payment, e.g. hort week, overtime, eaona earning, bonu or commiion, tatutory ick pay, tatutory maternity pay, etc. Peae give detai and amount of any expene Date of at rie Amount of rie per week/month Date of pending rie Amount of pending rie per week/month Date empoyment commenced If empoyment commenced after 1 Apri at, peae give gro earning to date in your empoy I your empoyee empoyed on a caua bai? Ye Part 3 - The empoyer i requeted to ign thi form and authenticate it with the firm officia tamp I confirm that the information given i true and compete Name Poition in firm Buine teephone number Signature Date Empoyer Addre Thank you for competing thi certificate, which you houd now return to Revenue & Benefit Department PO Box 505 Oakand Road, Hayward Heath Wet Suex RH16 1AQ 36

37 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page PAYMENT OF HOUSING BENEFITS DIRECT TO YOUR LANDLORD If you woud ike your Houing Benefit to be paid to your andord, peae fi Part 1of thi page and give it to your andord who mut then fi in Part 2. Peae note that payment wi normay be made direct to you une thi form i igned by both you and your andord. Part1 Your Name Your andord /agent name Your addre Your andord /agent addre Iwoud ike any Houing Benefit to which Iam entited, to be paid direct to my andord/agent. Iundertand that the Counci doe not have to agree to do thi. Iaccept that the Counci can end thi arrangement at any time. Iagree to give 2week notice, and inform the benefit office of my reaon, if I want to end thi agreement. Signed Date Part 2 Iam the andord (or andord agent) of the peron named in Part 1 above. Iagree that I wi: write and te the Benefit Office if the tenant give notice to eave; write and te the Benefit Office if the tenant eave without giving notice; write and te the Benefit Office of any change in the tenant circumtance which Iknow wi affect the amount of Houing Benefit he or he i entited to; pay back any recoverabe overpaid Houing Benefit which i ent to me in repect of my tenant named above, a oon a Ihave received notification aying o. Thi wi be ubject to the appea proce. Iundertand that faiure to repay any overpayment wi reut in direct payment being withdrawn and that Iwi remain iabe for any overpayment which have not been repaid. Iundertand that you do not have to pay Houing Benefit direct to me. I undertand that if thi arrangement end, you wi te me and then pay any benefit entitement to the tenant. Ihave read and undertand the note on the revere of thi form. Signed Date Name (in bock capita peae) If you are managing agent, peae give the company addre Job Tite Name of the Bank or Buiding Society that you want u to pay benefit into Account Hoder Name Sort Code Branch Account. If you have any querie about the competion of thi form, peae teephone any of the above number. Peae return thi form to Revenue & Benefit Department, PO Box 505, Hayward Heath, RH16 1AQ. 37

38 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page 38 GUIDANCE NOTES NOTES FOR LANDLORDS AND AGENTS The Counci adminiter Houing Benefit and hep peope on ow income pay their rent. Your tenant ha given you thi form a he aked that payment of Houing Benefit are made direct to you. Peae be aware that it i not away poibe for the Counci to pay benefit to the andord if the tenant caim i deat with under Loca Houing Aowance (LHA) rue. Further information about LHA can be obtained from the Counci office or their webite. Before the Counci can tart to make any payment of Houing Benefit to which your tenant may be entited, you houd read thee note carefuy and then ign the decaration on the front of thi form. You houd then return the form to the Counci a oon a poibe. Payment of Houing Benefit (Rent Aowance) Payment are made at four-weeky interva, normay at the end of the four week. Houing Benefit i not a payment of rent, but i aitance toward the rent. Any hortfa between the rent due and the Houing Benefit mut be coected from your tenant. If you have any querie regarding the amount of the Houing Benefit ent to you, you mut ak your tenant. The Counci cannot divuge any information regarding a caim to a third party une your tenant give the Counci written authority to do o. Landord and Agent duty to report change in circumtance If you receive direct payment of Houing Benefit, you mut notify the Counci of any change in your tenant circumtance which you might reaonaby be expected to know coud affect the amount of the benefit. You mut te the Counci immediatey if your tenant eave the accommodation or if there i a rent increae or decreae. It i a crimina offence if you, dihonety or without good reaon, fai to notify the Counci about uch a change in your tenant circumtance. Overpayment of Houing Benefit Overpayment of Houing Benefit can be recovered from either the tenant, or from the peron to whom it wa paid, i.e. the andord or the agent. If recovery of an overpayment i ought from you and you do not repay it, the Counci can recover if from any future benefit entitement that you may be eigibe to receive in repect of any of your tenant. The recovery of uch an overpayment wi not affect the tenant rent iabiity, uch tenant wi be deemed to have paid their rent to the fu vaue of their benefit entitement. 38

39 31458pp Mid Suex Book Aria:HORSHAM BOOK 30/1/09 14:48 Page LANDLORD S STATEMENT Name of tenant The Property Do you own the property? Ye I confirm the above-named rent accommodation at: The Rent What i the fu rent payabe by your tenant? per week, four week, caendar month, quarter How many room are there in the property? Bedroom Living Room Dining Room Kitchen Bathroom/WC Other Date of the at rent increae Who ee ive in the property other than the tenant named on thi form? Doe the rent incude the foowing? Water rate Ye Heating Ye Lighting Ye Landord Detai Your name and addre Hot Water Ye Power for cooking Ye Other power Ye Ceaning Ye Laundering Ye Teephone Genera Couneing/Support Ye Mea If Ye, Ye breakfat unch evening mea I the rent in arrear? If Ye, how much rent are you owed? Ye The Tenancy On what date did the tenancy tart? On what date did your tenant move in? How ong i your tenant ikey to tay? Are you or your partner reated to your tenant, their partner or any of their chidren? If Ye, peae tate reationhip I confirm that the information given i true and compete Signed Date If you woud ike to add any further information peae ue a eparate heet. Thank you for your aitance. Woud you peae return the form direct to the addre hown on the revere of thi form or hand it to your tenant. 39