Application form for a Discretionary Housing Payment

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1 Application form for a Discretionary Housing Payment The Council has a fund to provide extra financial help to people who get Housing Benefit, but are having trouble meeting housing costs. These payments are known as Discretionary Housing Payments. Who can apply? You must be getting some Housing Benefit or the rental cost element of Universal Credit and appear to the Council to need additional financial assistance to help meet housing costs. Housing costs could be ongoing rent payments and/or any one off costs associated with your housing needs. Council Tax We cannot help you if you are having trouble paying your Council Tax. You can apply for Council Tax Reduction, but if are still having trouble paying your Council Tax bill, you can ask the Council Tax Section for a reduction in your Council Tax due to financial hardship and if you can prove there is or has been exception unforeseen circumstances. How we make our decision As this is discretionary fund, we look at many different things to see if a DHP can be made in each case. We do look to see if you have any exceptional reasons for asking for this help. We also make sure that the DHP will actually help alleviate the difficult circumstances you are in. In the case of a weekly award we will look at all your income coming in and all your expenditure. We also take into account what you are doing or can do to make sure you can meet your housing costs yourself in the future. How long are DHPs paid for? DHPs are normally only paid for a short time and will depend on your circumstances. When a DHPs award ends you can reapply but account is taken of the efforts you have made since to ensure you can meet your housing costs. What happens if you disagree with our decision? We will send you a letter to let you know about the decision we made. There is no right of appeal, but you can ask us to have another look at the decision if you don t think it s correct. You should do so within one month of the date of the decision letter. Where to return the completed form by post : Benefit Services, PO Box 71, Llandrindod Wells, LD1 9AQ. by in person: Any Powys Customer Service Point Telephone: or Website: Changes of Circumstances If you are awarded a DHP you must tell us immediately if there is any change in your circumstances that might affect your award.

2 DISCRETIONARY HOUSING PAYMENTS Section 1 Surname: First Name: About You National Insurance No: Address: Postcode: Phone Number: Please note that if you provide an address it means that you agree to us contacting you by this method. Please tick to show which type of tenancy you are in (who you pay your rent to). Private Council Housing Association Section 2 The help you need Which housing costs are you applying for help with (please tick)? Ongoing Rent Rent in Moving rent deposit advance costs payments Essential furniture Other* * Please put down any other help you need here. Whilst we can t give help towards every cost, we can look at anything relating to your housing costs and needs. It may be that you are struggling to find work due to the nature of your housing situation or that there are extra fuel costs involved in where you live. You might need help with budgeting or managing your debts or it might be that you live in a rural area and there are additional costs or needs associated with that.

3 Please explain below why you need this help. Explain how this need has arisen. For example you may have been affected by the welfare reform changes such as the Benefit Cap or Bedroom tax. Also explain what your difficult or exceptional needs are and why. When do you need this help from until How will an award of DHP help improve your circumstances or situation? are or will be taking to improve your situation? Please explain what steps you Section 3 Income Please provide details of EVERY income that you and everyone else in your household receives from any source. Amount Income Type How Often To Whom Please provide details of any income that you or anyone else in your household has applied for and are waiting to hear about? This could include help from a voluntary body or a grant. It could be a benefit claim or a loan. Have you applied for any of the following? Discretionary Assistance Fund Budgeting Loan Credit Union Loan Yes/No If yes, what was the outcome Section 4 Capital

4 Please tell us the total amount of capital [i.e. savings and investments] held by you and any partner. Section 5 Rent Information Have you asked your landlord to reduce your rent liability? (circle) Yes / No If yes what was the outcome? If no, please explain why not. Have you tried to obtain suitable, cheaper accommodation? (circle) Yes / No If yes what was the outcome? If no, please explain why not. required to give to end your tenancy? How much notice are you Section 6 Expenditure Please provide details of ALL your outgoings. You MUST put everything down that you pay out for and the correct amount. We will use this to see how we much we can help you so it needs to be correct. If you need help with this please ask us. Expenditure Amount How Often How much is to pay for arrears? Mortgage Mortgage repayment policy Rent Council Tax Building insurance Contents insurance Electricity Gas Other heat/fuel cost Water charges Life insurance Food / groceries / toiletries Pension TV licence TV / Sky / cable

5 Telephone line / broadband Travel expenses Clothing and shoes Maintenance payments School meals / meals at work Laundry Health costs Mobile phone Spending / leisure money Alcohol / cigarettes Car servicing / tax / mot Car insurance Car petrol Pocket money Child minding / nursery Pet costs Court fines Hire purchase agreements Loans or credit agreements Store credit agreements Credit card debts Catalogue debts Other Other Other Other Section 7 Payment Where a one off payment is to be awarded we will look to make payment to the provider of the service or goods that you require. If you know who will provide that service, please provide their details here. Name Address Bank Account Sort Code Section 8 Further Information Have you applied to go on the waiting list for: Housing Association Yes / No Date: Council Housing Yes / No Date: If not please state why not:

6 Do you or any member of your family have any disabilities, or health problems, which means that you require special needs from any accommodation? If yes provide details adapted for disability reasons? If yes provide details Have you had the house that you currently live in specially Are you receiving support/ help regarding your financial and housing situation from any of the following (please circle) : Powys Housing Options Team Yes / No Powys Citizens Advice Bereau Yes / No Shelter Cymru Yes / No Other Advice Agency or Yes / No Their support worker Name: Please ask who ever is helping you to provide a written statement of support and attach it to this claim. The statement should help explain in more details what we have asked you in Section 2 (The help you need), and provide any other issues or implications they need us to consider before we make a decision. Please write below any further information that you want us to consider:

7 SECTION 9 How we collect and use information We will use the information you give us in this form, and any supporting evidence you send us, to process your claim for Discretionary Housing Payments. We will also use the information to help process any claims for Housing Benefit, Council Tax Reduction and Free School Meals. We may pass the information to other sections within Powys Council, agencies or organisations such as the Department for Work and Pensions, the Inland Revenue, as allowed by law. This authority is under a duty to protect the public funds it administers, and to this end we may use the information you have provided on this form for the prevention and detection of fraud. We may also share this information with other bodies or council services responsible for auditing or administering public funds, to assist with those purposes. We may check information you have provided, or information about you that someone else has provided, with other information held by us. We may also get information about you from certain third parties, or give them information to: make sure the information is accurate prevent or detect fraud and any other crime; protect public funds; support National Fraud Initiatives this may include your information being used in data matching exercises. These third parties include government departments, local authorities and private-sector companies such as banks and organisations that may lend you money. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to. We, Powys County Council, are the data controller for the purposes of the Data Protection Act Your personal information will be held and used in accordance with the requirements of the Data Protection Act If you want to know more about what information we have about you, or the way we use that information, write to us at: The Benefits Manager, Powys County Council, PO Box 71, Llandrindod Wells, Powys LD1 9AQ. SECTION 10 Sharing Information With your Landlord The Awards Service will only share information about your DHP claim with your landlord if you allow us to. We will only share this information if it will help us to make a decision on your claim for DHP and help prevent rent arrears. We would only tell your landlord:- that you have claimed DHP; the date you claimed; whether we have made a decision on

8 your claim; whether we need more information from you to decide your claim, and when we asked you for the information; and whether or not your claim was successful. We would not share your personal or household circumstances; or your financial circumstances. If you do not want us to share this information with your landlord please tick here. With your advisor, advocate or support worker If you have someone who is supporting or helping you with this DHP application process, we will share all information concerning your DHP claim with them including your personal, household or financial circumstances. We will also discuss with them any aspect of your DHP claim process if it is relevant. You should put their details at the end of Section 11 below so we know who is helping you. If you do not want us to share this information with your advisor, advocate or support worker please tick here. Free School Meals We will automatically work out from the information you have provided if you qualify for free school meals for any of your children. We will write and let you know. If you do not want to apply for Free School Meals even if you qualify for them, please tick here. Section 11 Your Declaration Please read this declaration carefully before you sign and date it. You must sign it if you can, even if someone else has filled in the form for you. If I give information that is incorrect or incomplete, you may take action against me. This may include court action. You will use the information I have provided to process my claim for Discretionary Housing Payments. You may make any enquiries needed to check the information I have given, including checking with other sources within the Council, and other councils and organisations as allowed by law. You may use the information I have provided in connection with this and any other claim for Social Security benefits that I have made or may make.

9 You may give some information to other organisations, such as government departments, local authorities, other council services and private-sector companies such as banks and organisations that may lend me money, if the law allows this. I know I must let the Benefits Service know straight away, in writing, about any changes in my circumstances that might affect my claim, including a change of address. I declare the information I have given on this form is correct and complete. Applicant s signature Date Put here your advisor s, or support worker details or the person who is helping you with this form. See Section 10 above as well. Name, address & contact details Relationship to you or their role

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