A Claim Form for Housing Benefit and Council Tax Reduction

Transcription

1 Issue Date: Benefit Reference No: Property Reference No: A Claim Form for Housing Benefit and Council Tax Reduction East Lothian Council, Support Services, PO Box 13261, Haddington, East Lothian, EH41 3YG. Important We will use the information you give in this form, and in any supporting evidence you send us, to process your claim for Housing Benefit and Council Tax Reduction. By law, we may pass the information to other agencies or organisations such as the Department for Work and Pensions, the Employment Service and Her Majesty s Revenues and Custom (HMRC). By law, we may also check the information you have provided, or information provided about you by someone else, against other information we already have. We may also ask other agencies, organisations, local authorities or government departments what information they have about you to ensure: it is accurate; to prevent or detect crime; and to protect public funds. We will not give information about you to anyone else, or use information about you for other purposes, unless the law allows us to. East Lothian Council is the data controller for the purposes of the Data Protection Act East Lothian Council is committed to treating all people equally. If you feel we have treated you unfairly, please contact our Equal Opportunities Officer on Use black ink to fill in the form. Do not use pencil. If you make a mistake, just cross it out and put the right answer next to it. Do not use correction fluid or tape. Please write clearly and answer all the questions. If a question does not apply to you, write N/A (not applicable). Name: Address: Please tick the appropriate boxes below: I own the home I live in I am a council tenant Post Code: Telephone: You do not have to tell us your phone number but it may speed up your claim. I am a private tenant I am a Housing Association tenant I live with one of the above I wish to claim council tax Single Persons Discount Is this your first claim at this address? Yes No If YES, what date did you move in? What was your previous address? Did you claim benefit there? Yes No Did you own this property? Did you rent this property? Yes No Yes No 1

2 Part 1 About you and your partner By partner we mean the person you are married to, or live with as if you were married, or have a civil partnership with. Your personal details You Your partner Marital status Title (Mr/Mrs/Ms/Miss) Last name First name Date of birth Letters Numbers Letter Letters Numbers Letter National Insurance Number (You can find this on pay slips or letters from the Department for Work and Pensions or Her Majesty s Revenues and Custom (HMRC). We cannot decide your claim if we do not have your National Insurance Number.) Have you lived in the UK for less than 2 years? If YES, what is your nationality? (We will write to you about this) Yes No Yes No Which country did you live in? When did you come to live in the United Kingdom? How long do you plan to stay? Do you still have bank accounts or property overseas? You and your partner s health You Your partner Are you long-term sick or disabled Yes No Yes No and incapable of work? Are you registered or certified blind? Yes No Yes No Does anyone get Carer s Allowance Yes No Yes No to look after you or your partner? If YES, what is their name and address? Are you in hospital at the moment? Yes No Yes No If YES, please state the date you went in? When do you expect to come out? 2

3 You Your partner Please tick if you or your partner are: a student (also complete 6b) a student (also complete 6b) a student nurse a student nurse an apprentice an apprentice on youth training on youth training in legal custody in legal custody severely mentally impaired severely mentally impaired PROOF We need to see two original items of identification (one photo ID if possible) before we can assess all new claims. We cannot accept photocopied documents. These could include: driving licence; national insurance card; valid passport; recent credit card bill; birth certificate; medical card; DWP letter; marriage certificate; recent payslip. If you do not have two items from this list, please contact us and we will advise you further. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. We need to see the original proof of your national insurance number before we can assess your claim. This could be P45, P60, payslips, income tax letter, DWP letter of award, RD3 national insurance card. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. Part 2 About children You may be able to get extra benefit for children you receive child benefit for, if they normally live with you and they are: i) under 16; ii) 16 or over, but under 20 and in full time education or approved training; iii) aged 16 or 17 and registered for work or youth training. Do you want to claim for any children? Yes No Tell us about the children If NO, go to Part 3 you want to claim for If you want to claim for more than three children, use a separate sheet of paper. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box Last name First names Date of birth What is the child s sex? The child s relationship to you Usual address if different from yours First child Second child Third child School attended Child Benefit Number 3

4 Who gets the Child Benefit for them? (We need to see proof of this) Is the child registered blind or Yes No Yes No Yes No getting Disability Living Allowance or Personal Independence Payments (PIP)? Do you pay any child minding Yes No Yes No Yes No costs for this child? Tell us the name, address and registration number of the minder How much do you pay a week? We need to see proof (see note below) Do you have a child about to Yes No Yes No Yes No leave school? If YES, what is their expected leaving date? PROOF We must have original proof of any money you pay for registered childcare costs. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. Part 3 About other people who live with you Please give details of anyone else who lives in your home. They could be relatives, friends or boarders. Do any adults normally live with you and your partner? Yes No (By adults we mean people over 16 for If YES, tell us about all the If NO, go to Part 4 whom no one receives Child Benefit ). adults, except your partner, who usually live with you. If you want to tell us about more than three people, use a separate piece of paper. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box Are any of the people who Yes No normally live with you married to each other or living together as if they were married? If YES, tell us their names. is the partner of is the partner of Now tell us about all the people who normally live with you and your partner. First person Second person Third person Last name First names Date of birth 4 Their relationship to you For example, aunt, brother, daughter, father, grandmother, stepdaughter, joint tenant, joint owner or friend

5 National Insurance Number Do they get Income Support or Yes No Yes No Yes No Income Based Jobseeker s Allowance or Employment and Support Allowance? Do they get Disability Living Allowance Yes No Yes No Yes No or Attendance Allowance or Personal Independence Payments (PIP) or are they registered blind? Are they a full time student, Yes No Yes No Yes No a student nurse, a care worker, an apprentice or on youth training? Do they pay rent or money for board Yes No Yes No Yes No and lodgings to you or your partner? Are they Severely Mentally Impaired? Yes No Yes No Yes No Are they in legal custody at Yes No Yes No Yes No the moment? If YES, when are they expected to come out? Are they in hospital at the moment? Yes No Yes No Yes No If YES, when did they go in? When are they expected to come out? Do they normally work for Yes No Yes No Yes No 16 hours or more a week? If YES, tell us about their earnings before deductions for things like National Insurance. We need to see proof of their earnings. Do they have any other income Yes No Yes No Yes No or savings at all? If YES, tell us their other income before deductions for things like Tax and National Insurance. We need to see proof of their income. PROOF We must have proof of the income and savings of all the people you have told us about in this section. This will help us work out any benefit you could get for Second Adult Rebate. If you do not provide this proof, you will NOT be considered for Second Adult Rebate and the highest rate of non-dependant deduction will be taken off any benefit paid to you. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 5

6 Part 4 Capital, bank accounts, savings and investments By capital we mean any money you have in banks or buildings societies, INCLUDING your current account (if you have one). This also means investments like stocks and shares, and property or land that you own (other than the home you live in). Do you, or your partner, have any capital, Yes No bank accounts, savings or investments? Answer all the questions If NO, go to Part 5 in this part. (This includes current accounts and savings accounts with a bank or building society, post office accounts, premium bonds or stocks and shares) We need to see proof of all the capital, savings and investments. Do you or your partner have any bank accounts? Yes No (current and/or savings) Tell us about bank accounts. If there are more than 3 bank accounts, tell us about the others on a separate piece of paper and send it with this form. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box Name of bank Account number Whose name is the account in? How much is in the account? Do you or your partner have any building Yes No society accounts? Tell us about these building society accounts. If there are more than 3 building society accounts, tell us about the others on a separate piece of paper and send it with this form. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box Name of building society Account number Whose name is the account in? How much is in the account? Do you or your partner have any Yes No post office accounts? (This includes savings accounts and girobank accounts) Tell us about these post office accounts. 6

7 If there are more than 3 post office accounts, tell us about the others on a separate piece of paper and send it with this form. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box Type of account Account number Whose name is the account in? How much is in the account? You Your partner Do you or your partner Yes No Yes No have any Premium Bonds? Do you or your partner Yes No Yes No have any National Savings Value: Value: Certificates? How many? How many? (Please provide us with the original certificates as proof) Do you or your partner Yes No Yes No have any Stocks, Shares, Bonds Company name: Company name: or Unit Trusts? How many? How many? Do you or your partner Yes No Yes No have any other capital, savings If YES, tell us about this: If YES, tell us about this: or investments? (Tell us about any TOISA s or ISA's or PEPS here) Do you or your partner own Yes No Yes No or partly own any land or property If YES, tell us the address If YES, tell us the address other than the home you live in? PROOF We must see proof of all your capital before we can assess your claim. We must see original documents, like a full up to date bank statement showing at least 8 weeks transactions, building society books, savings book, savings certificates, share certificates and property deeds. If you don t have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. Part 5 About working Do you or your partner work for an employer? Yes No Answer the following If NO, go to Part 6 questions. If you work for more than one employer, tell us about the employers on another piece of paper and send it with this form. If you are sending a separate sheet of paper, clearly note on it your name and address and tick this box 7

8 You Your partner What kind of work do you do? What is your employer s name and address? When did you start this job? Are you employed for a Yes No Yes No limited period? If YES, what date will it end? How often do you get paid? Every Every How much do you get paid? When was your last pay rise? How many hours a week do you work? Are you getting Statutory Sick Pay Yes No Yes No (SSP) or Statutory Maternity Pay (SMP) from your employer at the moment? Are you getting any other sick pay Yes No Yes No or maternity pay from your employer at the moment? Do you pay into a private or Yes No Yes No company pension scheme? If YES, how much If YES, how much How often? How often? Do you get tips, bonuses or Yes No Yes No commission? If YES, how much If YES, how much How often? How often? PROOF We must see original proof of all your earnings before we can assess your claim. We cannot accept photocopies. If you do not give us sufficient proof of your earnings, we may have to contact your employer. if you are paid each week, send or bring in to us your last 5 weekly payslips. if you are paid two weekly, send or bring in to us your last 3 fortnightly payslips. if you are paid each month, send or bring in to us your last 2 monthly payslips. if you do not have this proof, ask your employer to fill in and sign the Employer s Certificate on page 9. then return it to us with your last payslip. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 8

9 East Lothian Council, Support Services, PO Box 13261, Haddington, East Lothian EH41 3YG. Certificate of Earned Income/Benefit Income You Only fill in this form if you cannot give us your payslips or evidence of your state benefits. Please fill in your personal details below. If you are working, ask your employer to fill in and stamp section A. If you get state benefits, ask an officer at the DWP to fill in and stamp section B. Once you have done this, return the certificate to the address above. Name: Address: Section A To be completed if you are working Note to Employer: Please fill in section A of this certificate and return to your employee. Thank you for your help. East Lothian Council, Support Services, PO Box 13261, Haddington, East Lothian EH41 3YG. Certificate of Earned Income/Benefit Income Your partner Only fill in this form if you cannot give us your payslips or evidence of your state benefits. Please fill in your personal details below. If you are working, ask your employer to fill in and stamp section A. If you get state benefits, ask an officer at the DWP to fill in and stamp section B. Once you have done this, return the certificate to the address above. Name: Address: Section A To be completed if you are working Note to Employer: Please fill in section A of this certificate and return to your employee. Thank you for your help. Employee / works number Please tick the box to say how often the employee is paid: weekly fortnightly 4 weekly calendar monthly other (please state) Normal basic wage: Normal hours worked: Method of payment: Pay period Gross pay Gross pay National Superannuation Income Tax ending to date Insurance or pension Employee / works number Please tick the box to say how often the employee is paid: weekly fortnightly 4 weekly calendar monthly other (please state) Normal basic wage: Normal hours worked: Method of payment: Pay period Gross pay Gross pay National Superannuation Income Tax ending to date Insurance or pension 9

10 Your partner If statutory Sick Pay or Maternity Pay is included in the gross pay, please indicate which is paid and how much. Sick Pay Maternity Pay Name and business address of employer Employer s signature: Date: Please endorse this certificate with the employer s authorisation stamp below: Section B To be completed if you get state benefit Note to DWP Officer: Please fill in the requested details below and return to the claimant. Thank you for your help. Address of DWP claim: Type of benefit Date started Date benefit ends Weekly amounts Signature of DWP Officer: Date: Please endorse this certificate with the DWP authorisation stamp below: You If statutory Sick Pay or Maternity Pay is included in the gross pay, please indicate which is paid and how much. Sick Pay Maternity Pay Name and business address of employer Employer s signature: Date: Please endorse this certificate with the employer s authorisation stamp below: Section B To be completed if you get state benefit Note to DWP Officer: Please fill in the requested details below and return to the claimant. Thank you for your help. Address of DWP claim: Type of benefit Date started Date benefit ends Weekly amounts Signature of DWP Officer: Date: Please endorse this certificate with the DWP authorisation stamp below: 10

11 Part 6 About any other work Do you or your partner do any other Yes No work at all? If YES, answer the questions If NO, go to Part 7 (This could be voluntary work on this page. or any other work, even if it is not paid). You Your partner What kind of work do you do? What is the name and address of the person you do this work for? When did you start this work? Do you get paid? Yes No Yes No If you only get expenses or tips, Still tick Yes and give details. If YES, how much? If YES, how much? How often? How often? PROOF We must see original proof of all your earnings before we can assess your claim. We cannot accept photocopies. If you don t give us sufficient proof of your earnings, we may have to contact your employer. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. Part 6b Are you a student? (student means someone who is in further education and beyond school level). Are you or your partner a student? No If NO, go to Part 7 Yes If YES, give details below STUDENT INCOME Value of grant You Your partner Value of any money paid by parents or deed of covenant COURSE DETAILS Name and type of course Date academic year starts Date academic year ends When does the whole course end? You Your partner 11

12 Part 7 About being self-employed Are you or your partner self-employed? Yes No If YES, answer the questions on this page. If NO, go to Part 8 You must send us your trading accounts for the last financial year. If you have only recently set up the business and do not have a full year s accounts, we will need to see some other proof of your income. We will write to you about this. You Your partner What kind of work do you do? When did the business start? What is the business address? Are there any other partners Yes No Yes No in the business? How many hours a week do you work? Do you get a business Yes No Yes No start up allowance? Do you pay into a private Yes No Yes No pension scheme? PROOF We must see original proof of all your earnings before we can assess your claim. We cannot accept photocopies. Please send or bring in your most recent audited accounts. If you have been self-employed for less than a year, we will need proof of the estimated earnings you have told us about. We need to see your latest personal and business bank statements and your latest tax assessment. If we need further proof we will ask you for this as soon as possible. If you do not have this proof now you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 12

13 Part 8 About Income Support, Income Based Jobseeker s Allowance, Employment and Support Allowance (income related) and Pension Credit Are you or your partner getting or waiting to hear Yes No about a claim for Income Support or Income Based If YES, answer the If NO, go to Part 9 Jobseeker s Allowance or Employment and Support following questions Allowance (income related) or Pension Credit? You Your partner Are you or your partner getting Income Yes No Yes No Support or Income Based Jobseeker s Allowance at the moment? When did you start getting it? Are you or your partner getting Yes No Yes No Employment and Support Allowance (income related) at the moment? When did you start getting it? Are you or your partner getting Yes No Yes No Pension Credit at the moment? When did you start getting it? Are you or your partner getting Yes No Yes No guaranteed element of Pension Credit? When did you start getting it? Are you or your partner getting the Yes No Yes No savings element of Pension Credit? When did you start getting it? PROOF We must see original proof of all the payments you have told us about before we can assess your claim. We cannot accept photocopies. If you do not have this proof now you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 13

14 Part 9 About benefit and pensions Are you or your partner getting any benefit or waiting Yes No to hear about benefits you have claimed? If YES, tell us If NO, go to Part 10 about the benefit If you are getting or have claimed any benefit that is not listed, tell us about it at the bottom of the list. You Your partner Waiting to How much? How often? Waiting to How much? How often? hear ( ) ( ) hear ( ) ( ) Attendance Allowance Carer s Allowance Child Benefit Child Tax Credit Disability Living Allowance Care Disability Living Allowance Mobility Employment and Support Allowance (contribution based) Guardians Allowance Incapacity Benefit (long term) Incapacity Benefit (short term lower rate) Incapacity Benefit (short term high rate) Industrial Death Benefit Industrial Injuries Disablement Benefit (Contribution based) Jobseeker s Allowance Maternity Allowance Personal Independence Payments (PIP) Retirement Pension Severe Disablement Allowance Statutory Sick Pay War Disablement Benefit War Pension War Widow s Pension Widow s or Widower s Benefit Working Tax Credit 14

15 Part 10 About other money coming in Do you or your partner or any children you are claiming Yes No for, have any money coming in that you have not If YES, tell us about If NO, go to Part 11 already told us about on this form? the benefit below (This includes any money like pensions from a previous employer, cash-in-lieu payments, maintenance or child support for you, your partner or any of the children, you have told us about on this form; and any cash payments. Also tell us about any money you get from people living in your house as boarders, lodgers or subtenants. You do not have to tell us about payments from the Independent Living Fund, the Eileen Trust or the MacFarlane Trust.) Other money 1 You Your partner What is the money for? Who gets it? How much do they get? How often? Other money 2 What is the money for? Who gets it? How much do they get? How often? Other money 3 What is the money for? Who gets it? How much do they get? How often? Does anyone owe money to you, your partner or any children you are claiming for? Yes No If YES, what for? How much? PROOF Before we can assess your claim we need to see original proof of all the unearned income you have told us about. We cannot accept photocopies. We need to see proof that shows us how much unearned income you get, and how often you get it. This could be something like a recent payslip, a DWP letter along with a full latest bank statement. Alternatively, ask your DWP officer to fill in and sign the Benefits Certificate on page 9, then return it to us as soon as possible. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 15

16 Part 11 About rent Do you pay rent for your home? Yes If YES, complete this section No If NO, go to Part 14 Do you pay rent to the council? Yes If YES, go to Part 12 When did you start renting your home? When did you move to this address? If you have not moved in yet, tell us when you expect to move in? Does your landlord live in the property? Yes No What sort of tenancy do you have? For example, shorthold, tied rent etc. How long is the tenancy for? to Please tick to show if the property is let as: furnished partly furnished minimally furnished unfurnished Does your home have central heating? Yes No Who pays for decorating the inside of your home? How much rent do you pay? every Does anyone else share the rent with you and your partner? No Yes Tell us their names Has your rent changed in the last 12 months? Have you owned this property within the last 5 years? Do you have any weeks when you do not have to pay rent? No Yes Send us proof of the date it changed, and how much it changed Yes No Yes No 16

17 Are you in arrears with your rent? Yes No If you have ticked yes, state how much If you have ticked yes, state period If you know in advance when you rent is due to be increased, please enter the date Who pays the Council Tax on your home? Are you living away from home at the moment? you and your partner your landlord someone else No Yes Tell us why you are not living at home When did you last live at home?.../.../... When do you expect to go back home?.../.../... Tell us the address of where you are living at the moment If your home has been sub let, tell us who lives there now Does the rent include money for: meals heating lighting hot water fuel for cooking laundry cleaning rooms or windows No Yes How much? For which meals? Breakfast Please tick Lunch Dinner No Yes How much? No Yes How much? No Yes How much? No Yes How much? No Yes How much? No Yes How much? 17

18 gardening garage or parking space Do you have to rent the garage as part of your tenancy agreement? personal care and support No Yes How much? No Yes How much? Yes No No Yes How much? Do you pay any service charges No separate from your rent? Yes How much? For example, for cleaning or lighting in What for? shared areas, an alarm system, a warden, general counselling or support meals or lift maintenance What is your landlord s full name and address? By landlord we mean the person or organisation who owns the property you live in. What is your landlord s registration number? If your landlord has an agent tell us their full name and address. Agent means the person or organisation who you actually pay your rent to. Are you, or your partner or No children related to your Yes What is the relationship? landlord or agent, or to your landlord s partner or the agent s partner? Related includes related through marriage, even if the marriage has ended. PROOF Before we can assess your claim we need to see original proof of your rent. This should be a tenancy agreement, lease, rent book or letter from your landlord. If your rent has been registered with the rent officer, we need to see the notice of registration (form R05). If the proof you give us is not sufficient, we may contact your landlord. If you do not have this proof now, you can send or bring it in to us within one calendar month. You must complete this form and return it straight away. IF YOU DO NOT YOU COULD LOSE BENEFIT/REDUCTION. 18

19 Part 12 About where you live What sort of building do you live in? detached house flat in a block caravan, mobile home or houseboat semi detached house flat in a house board and lodgings terraced house flat over a shop hotel maisonette bedsit or room residential nursing home bungalow hostel residential care home other please state Which floor is your home on? 2nd floor 1st floor ground floor basement Other please specify Do you and your household occupy only part of the No Yes building? Where in the building do you live? At the front In the middle At the back How many rooms are there In the whole Just for you and That you share with in the building? building your household other people living room bedsitting room bedrooms bathrooms toilets kitchens other rooms Do you use your home for business? Do you have a main home somewhere else? (If your main home is elsewhere in the UK or abroad, tick yes, even if you do not pay rent for it.) Yes No No Yes What is the address? How much do you pay for this home? 19

20 Part 13 Other Information Sharing information with your landlord 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 we have your permission to contact your landlord, this may help speed up your claim. If you give us permission, we would be able to tell your landlord whether: you have claimed Housing Benefit we have made a decision on your claim we have made a payment to you; or we need more information to make a decision on your claim, and what that information may be We will not give your landlord any information about: your personal or household circumstances; or your financial circumstances You can withdraw your permission at any time. It will not affect your claim if you do not give us permission to discuss your claim with your landlord. If you want to give us your permission to discuss your claim with your landlord, please sign below. I give East Lothian Council permission to share any information about the progress of this housing benefit claim with my landlord or their nominated representative. You or your partner s signature: Date: Part 14 Paying your Housing Benefit If you are a council tenant, your council will pay any Housing Benefit you are awarded into your rent account. If you are not a council tenant and are awarded Housing Benefit, in most cases you can choose where to have your money paid. Your council can arrange to pay your money: straight into a bank or building society by cheque If you are awarded Council Tax Reduction, we will pay this into your council tax account. In some cases we can pay your landlord direct. Payment direct into a bank account We recommend that you get your money in this way because: it is safe and secure it is convenient you decide when and how much you want to withdraw using an account may help you to save you could have regular bills paid from some accounts (this could save you money but you will need to make sure that there is enough money in your account to pay the bills if not, you may be charged a fee) you can get your money from many different places 20

21 The account can be: in your name in the name of your partner (we use partner to mean a person you are married to or a person you live with as if you are married to, or a civil partner or a person you live with as if you are civil partners) in your name and your partner s name in the name of the person acting on your behalf in your name and the name of the person acting on your behalf If we cannot pay into your account, we will pay you by cheque. Please note that we cannot make payments into post office card accounts. You must tell us how you want us to pay your Housing Benefit. Would you like your Housing Benefit paid straight into a bank account or by cheque? Tick the appropriate box. straight into a bank account by cheque Private tenants getting Local Housing Allowance (LHA) Your benefit will be paid directly to you. If you feel there is a reason why you could not manage your own rent payments you should contact us for a Direct Payment to Landlord form. Name of bank or building society Address Account name Account number Sort code Housing Association and tenants exempt from Local Housing Allowance (LHA) Housing Benefit can be paid to you or direct to your landlord (please complete either Option 1 or Option 2) OPTION 1: I want my Housing Benefit paid into my bank or building society Name of bank or building society Address Account name Account number Sort code OPTION 2: I want my Housing Benefit paid direct to my landlord s bank account Name of bank or building society Address Account name Account number Sort code 21

22 Part 15 Anything else you need to tell us? Use this box to tell us anything else you think we should know about. Use a separate sheet and attach it to this form if you need to. If you are sending a separate sheet of paper, tick this box Part 16 Scribe By scribe we mean someone who writes the claimant s details on the form because they are having difficulty filling it in for themselves. A scribe will usually be a council advisor or other advice worker. If you are acting as a scribe, please give your details below. If you are in any doubt about whether this section applies to you or not, please call the benefit section for advice on or Note: When you act as a scribe, you are not responsible for the person s benefit claim. The claimant must still sign the declaration below. I have read back to the customer the entries I made on the form based on the information given by them. The customer agreed they were correct. Name Occupation Employer Signature Claimant s signature 22

23 Part 17 Declaration Even if someone else has filled in this form for you, you must sign the declaration if you can. If you have a partner, they must sign this declaration as well. Please read this declaration carefully before you sign and date it. This is my claim for Council Tax Reduction/Housing Benefit/Single Person Discount. I declare that the information I have given on this form is correct and complete. I authorise East Lothian Council to make any necessary enquiries to check the information is true. I authorise East Lothian Council to cross-check the information I have given with other sections within East Lothian Council, Rent Service Scotland and other benefit authorities within the terms of the Data Protection Act. I understand that the data held by this authority in respect of my Benefit/Reduction Application will be used for cross-system and cross-authority comparison purposes for the prevention and detection of fraud. I understand that any information given on this form can be used for debt recovery purposes. I understand that if I give information that is incorrect or incomplete, I may be prosecuted. I must let East Lothian Council know in writing of any changes of circumstances which may affect my claim. Examples of changes of circumstances of which you must notify us of are listed in the separate guidance notes. I understand that if I fail to inform East Lothian Council of any changes, this may involve the recovery of any overpayment of benefit and also lead to possible prosecution or penalty. I understand that the data held by this authority in respect of my Benefit Application will be passed onto the Credit Reference Agency. I understand that East Lothian Council aims to provide a good quality service to me and all its customers to help ensure our safety and wellbeing. To assist East Lothian Council staff to deliver the best service possible I agree to my personal details being shared between relevant services within the Council. These services may include Housing and Environment, Adult Wellbeing, Children s Wellbeing, Finance and Education. I have read and understood the above declaration Signature of person claiming: Signature of partner/spouse/joint tenant as appropriate: Date Date 23

24 Your representative If this form has been filled in by someone other than the person claiming: Please tell us why you are filling in this form for the person claiming. Name of representative Address of representative Signature of representative Date Relationship to the person claiming Note: When you agree to act as a representative, you must take full responsibility for the person s benefit claim. This means you must make the claim and tell us of any changes in the person s circumstances. Checklist This section is to help you make sure you have filled in the form completely. IF NOT, YOUR CLAIM WILL BE DELAYED AND YOU COULD LOSE BENEFIT/REDUCTION. Is your full name and address on the first page? Have you enclosed proof of all money coming in? Have you enclosed proof of all savings and capital? Have you enclosed your tenancy agreement and rent book? (only if paying to a private landlord or housing association) Have you signed the declaration on page 23? Have you enclosed proof of your ID? If you have answered YES to all of the above, or are sending in proof within one calendar month, your application is ready. You can send your application to the address on the front page or bring it in person to any of the area offices listed in the notes for completing a claim form for Housing Benefit and Council Tax Reduction. 24

25 Equalities REVENUES: Equality Monitoring Document East Lothian Council, Support Services, PO Box 13261, Haddington, East Lothian, EH41 3YG. To link our information with national statistics, the questions in this section have been mainly taken from the 2001 Census. Please complete these sections. 1. Sex: Male Female I prefer not to answer 2. Date of Birth: (DD/MM/YYYY) I prefer not to answer 3. Marital Status: Single (never married) Married Cohabiting Widowed Separated Divorced I prefer not to answer 4. How do you identify your sexual orientation? Bisexual Gay/Lesbian Heterosexual I prefer not to answer 5. Disability: The Disability Discrimination Act 1995 defines a disability as a physical or mental impairment which has a substantial or long term adverse effect on a person s ability to carry out normal day-to-day activities. Using this definition as a guide, do you consider yourself to have a disability? Yes No If yes please give details: I prefer not to answer 6. What religion, religious denomination or body do you belong to? None Church of Scotland Roman Catholic Other Christian (please give details) Buddhist Hindu Sikh Muslim Jewish Another religion (please give details) I prefer not to answer 25

26 Ethnic Origin Choose a section A-E and complete. A White Scottish English Irish Welsh Other (please give details) B Mixed Background Any mixed background (please give details) C Asian (Asian Scottish, Asian English, Asian Welsh, Other Asian British) Indian Pakistani Bangladeshi Chinese D Black (Black Scottish, Black English, Black Welsh, or other Black British) Caribbean African E Other Ethnic Background (please give details) Other White Background (please give details) Any other Asian background (please give details) Any other Black Background (please give details) I prefer not to answer 26

27 CR1632 3M 313