Discretionary Housing Payment (DHP) claim form

Transcription

1 Discretionary Housing Payment (DHP) claim form A DHP may be awarded where there is a shortfall between your benefit and your rent. It cannot be awarded to help with Council Tax. If you wish to apply for a DHP you should complete this form in full, and give as much information as possible and provide proof of your income and expenditure. When your DHP award ends you will need to reapply if you still require this help. SECTION A Name: Address: Date: Our ref: Ask for: Benefit Service Postcode: Telephone Number: Why do you think a DHP should be paid? Please state how many weeks would you like this help for; please give reasons for the length of time you have requested. 1

2 SECTION B So that we can understand what effect the shortfall is having on your family s budget, please give full details below of weekly amounts of your income and your outgoings. Weekly income How much Your wages (after tax and national insurance) Your partners wages (after tax and national insurance) Self employed earnings Job Seekers Allowance (Contribution based) Income Support or Job Seekers Allowance (Income based) or Employment Support Allowance (Income related) Universal Credit (please provide your award letter) Incapacity Benefit or Employment Support Allowance (Contribution) Retirement Pension Pension Credits Works pension or superannuation payment Maintenance received Child Benefit Working Tax Credit Child Tax Credit Any other hardship or discretionary payments Money from other adults who live with you Any other income please give full details TOTAL Weekly outgoings How much ( ) Rent - please state the amount you are charged. (If you receive Universal Credit, you will need to provide proof of your rent liability i.e. your tenancy agreement). Buildings or contents insurance Life assurance Council Tax Water rates or water meter charge Gas Electricity Food/Housekeeping Meals at School/work Maintenance payments Childminding TV licence Telephone landline/mobile Internet or broadband Clothing Car Costs Social Fund/Crisis Loans Other please state Other please state Rent Arrears Council Tax Arrears Fuel Arrears TOTAL 2

3 If any of your outgoings or payments are unusually high, please explain why: If you have any non-dependants in your household, please state below the amount they contribute to the following Expense Rent Council Tax Food Utilities Other Weekly Contribution State any other actions you are taking to improve your finances: SECTION C Household Details Please list the people who live in your household. Surname Other Names Date of Birth Relationship to you Please inform me how many bedrooms there are in your property. 3

4 SECTION D Do you or anyone who lives with you have any disabilities, health problems or special needs? Yes No If yes, please give full details and if this would prevent you from moving, please state why: Has the property been adapted in any way for anyone with a health problem? Yes No If yes, please give details Do you or your partner have a non resident carer who stays overnight in your home? Yes No If yes, does the carer have their own bedroom? Yes No Who is receiving the overnight care? Is this person in receipt of Attendance Allowance or Disability Living Allowance care component high or middle rate? Yes No If no, please provide proof that your or your partner have a medical need for overnight care, such as a letter from your doctor or a medical professional. I also require evidence that regular overnight care is provided by a non resident carer such as a letter from Social or the agency / person who provides the care. Are you single and currently expecting a baby? Yes No If yes, when is the baby due? 4

5 Do you have a Foster Child / Children residing with you? Yes No If yes, please give full details Has anyone within your household died within the last 12 months? Yes No If yes, please give full details Is there anything else which you would like us to consider when looking at your DHP application? If so, please give full details below. SECTION E Have you asked the landlord to reduce the rent? Yes No What did they say? 5

6 SECTION F Please confirm your bank account details. Name of account holder(s) Name and address of the bank / Building society Sort code - - Bank or Building Society account number Building Society roll or reference number We may consider paying the Discretionary Housing Payment to your Landlord if they receive your Housing Benefit payment or your Housing Element of Universal Credit. You will need to provide your Landlord s bank account details. Name of account holder(s) Name and address of the bank / Building society Sort code - - Bank or Building Society account number Building Society roll or reference number 6

7 SECTION G Please carefully read the following declaration before you sign and date it. I understand that if I do not state all my income, capital or circumstances that I may have to repay some or all of any money I receive from the Council. I understand that I must tell you about any changes in my income, capital or circumstances which may affect my entitlement to Housing Benefit, Council Tax Support or Discretionary Payment immediately. The information I have given is true and I have not deliberately missed anything out. The Council can check the information I have given and if I give false information I may be prosecuted. Your signature. Date. If someone else has filled in this form for you Please tell us why you are filling in this form for the person claiming. I declare that as far as possible, I have confirmed with the person claiming that the answers I have written on this form are correct. Name of person who filled in the form Signature Relationship to person claiming Date / / 7

8 Send the form and evidence to: Benefits Section, Tameside MBC, PO Box 304, Ashton-under-Lyne, Lancashire. OL6 0GA Or, you can bring the form and evidence to one of our Customer Service Centres at: Address Opening Hours Address Opening Hours Ashton Customer Clarence Arcade Stamford Street, OL6 7LT Monday-Wednesday, 8.30am pm Thursday, 8.30am pm Friday, 8.30am pm and Drop In Denton Customer Denton Town Hall Market Street, M34 2AP Dukinfield Customer Dukinfield Library Concord Way, SK16 4DB Droylsden Customer Droylsden Library Manchester Road Droylsden M43 6EP Hattersley Customer Peak Valley Housing Office The Hub Stockport Road Hattersley, Hyde SK14 6NT Hyde Customer Hyde Town Hall Corporation Street Hyde SK14 1AL Mossley Customer Mossley Library George Lawton Hall, Stamford Street Mossley OL5 0HR Stalybridge Customer Stalybridge Library Trinity Street Stalybridge SK15 2BN If you are a tenant of Ashton Pioneer Homes, Contour Homes, Irwell Valley Housing Association, Mosscare Housing Trust, New Charter Housing Trust, Peak Valley Housing, or West Pennine Housing Association help is also available at any of their advice centres. 8