Application for Financial Assistance

Transcription

1 East Ayrshire Council Application for Financial Assistance Disabled Adaptions, Work to eradicate Below Tolerable Standard Housing & Housing Improvements For Office Use Only Reference Number EAC / Disabled Adaptation (DA) Below Tolerable Standard Housing (BTS) Housing Improvement Programme (HIP) Do you, due to health issues, require assistance completing this paperwork? Yes No

2 Section 1 1A General Address of the property where work is to be done. Please include the flat number if applicable. Postcode 1B r details (the applicant) (Tick one box) Mr Mrs Miss Ms Surname Date of Birth Forename(s) Address (if different from A1) Phone (Day / Evening) Phone (Mobile) D: M: Postcode E: Are you disabled? Y N Are you registered blind? Y N 1C Who owns the house where work is to be done? If there are joint owners, please provide details in the Additional Information panel at the back of this leaflet. Owner s Name Owner s Address Phone (Day / Evening) Phone (Mobile) D: M: Postcode E: 2

3 1D If someone else is dealing with this application on your (the applicant) behalf, please give their details. Name Address Postcode Relationship to you Phone (Day / Evening) Phone (Mobile) D: M: E: Section 2 2A About the House What sort of property is it? Please tick one box. House: Detached Semi-detached Terraced Flat: Tenement High-rise 4-in-a-block Other 2B Please describe Please give a brief description of the planned works 2C How much will these works cost? Cost of work Professional fees VAT on work VAT on Professional fees TOTAL will need to provide full specifications for the work and estimates of the costs, including professional fees. 3

4 Section 3 3A and the House What is your connection with the house? Agricultural and crofting tenants are treated as owners for the purpose of this form. If this applies to you, please answer as if you were the owner. Owner Tenant Life-renter Other Please describe Section 4 4A Income Do you have a partner who normally lives with you? Yes No What is your partners name? Please include your partners income and circumstances in completing this part. Please include only your income and circumstances in completing this part. 4B Do you or your partner (where applicable) receive any of the following benefits? Income Support Gaurantee element of Pension Credit Income-based Job Seekers Allowance Employment Support Allowance 4C How much did you receive in earnings from employment and/or self employment in the past year? Enter the gross amount, minus income tax and NI contributions. Employment Self Employment r Partner 4D How much did you pay over the past year in contributions to occupational pensions (deducted from your pay) or personal pensions, including stakeholder pensions and retirement annuities? r Partner Occupational Personal 4

5 4E How much income did you receive from savings and investments, including annuities, unit trusts, shares etc. over the past year? Include all interest paid to any accounts, net of tax, even if it was re-invested. Income from Savings and Investments r Partner 4F How much did you receive over the past year from occupational pensions, pesonal pensions annuities, or state second pensions (S2P, or SERPS)? Do not include Pension Credit, or any war widows pensions. Income from Pensions r Partner 4G If you let any property to someone else, including letting rooms in your own home, what was the net taxable income from the letting over the past year? Enter the amount after subtracting expenses which are deductable for income tax purposes. Income from Rents r Partner 4H If you receive maintenance from anyone for your own support or to support a child you are responsible for, what was the total amount received over the past year? Do not include benefit payments or any payments from a local authority for looking after a child placed with you for fostering or adoption. r Partner Maintenance Payments 5

6 4I If you receive Housing Benefit, what was the total amount received over the past year? Housing Benefit r Partner 4J How much did you pay in rent or mortgage payments over the past year, for your own home? Include payments for any endowment policy or other investment or insurance products you are required to pay to stay in your home. Do not include other amounts for services, bills, additional insurance or council tax. Mortgage/Rent r Partner 4K How much did you pay in rent or mortgage payments, as above, for any other house where a member of your family lives? Only include payments which you are contractually required to make. r Partner Mortgage/Rent 4L(i) Were you or your partner responsible for any child under 16, or any young person between 16 and 21 and in fulltime education, for any part of the past year? Please tick one box and follow the instructions alongside. No Please go to question 4M. Yes Please complete the details below. 4L(ii) Please list the name and date of birth of each child or young person in the table below, and tick if they receive Disabled Living Allowance (DLA) or are registered blind Continue on a separate sheet if necessary. Child/ng Person s Name Date of Birth DLA / Blind 6

7 4L(iii) If the situation changed during the past year for any of the children listed in question D12b, please give details of the changes in the table below, showing the child or young person s name and the relevant dates. Name U16/U2 Student DLA/Blind Eg. Mary Smith 2 Nov Jun 03 2 Nov Jun 03 4M Are you or your partner registered blind, or receive any of the benefits listed below? Please answer YES or NO in each box. Registered Blind Disability Living Allowance Disability element of Working Tax Credit Disabled Person s Tax Credit Severe Disablement Allowance Incapacity Benefit Mobility Supplement Attendance Allowance Other similar benefit: Please specify r Partner 7

8 Section 5 Ethnic Monitoring Form The information requested on this form will help us to make sure we provide Council services fairly to all members of the community. If you prefer not to answer any of the questions, it will not affect the progress of you application. However, we will be able to provide more help with your application if you let us know of any particular needs. 5A What is your ethnic group? Choose one section from A to E and tick one box which best describes your ethnic group or background. (i) - White Scottish English Welsh Northern Irish British Irish Gypsy/Traveller Polish Other Please state (ii) - Mixed or multiple ethnic groups Any mixed or multiple ethnic groups Please state (iii) - Asian, Asian Scottish or Asian British Pakistani, Pakistani Scottish, or Pakistani British Indian, Indian Scottish, or Indian British Bangladeshi, Bangladeshi Scottish, or Bangladeshi British Chinese, Chinese Scottish, or Chinese British Other Please state 8

9 (iv) - African, Caribbean or Black African, African Scottish, or African British Caribbean, Caribbean Scottish, or Caribbean British Black, Black Scottish, or Black British Other Please state (v) - Other Ethnic Group Arab Other Please state 5B Would you prefer to receive information about this application in a language other than English? Chinese Punjabi Urdhu Polish 5C Would you prefer to receive information about this application in an alternative format? Large Print Braille Audio Tape Computer disc Other Please state 9

10 Section 6 All applicants must sign below. Applicants Declaration In order to process your application, East Ayrshire Council requires certain information from you, as detailed in the application form. This information, which may include details of your occupation, financial and ownership details, will be processed by us in accordance with the Data Protection Act This form gives us permission to share information which you have provided in your application form with other Council departments or to contact external agencies if we feel the need to verify the accuracy of the information provided by you on your application form. In the absence of your specific consent, as indicated below, we may contact you and ask you to provide supporting evidence of any details contained in your application before we can process your application fully. Declaration This is my application for financial assistance towards the costs described in my application form. I can confirm that the information provided by me in this application is, to the best of my knowledge, true and accurate. I understand that if I make a false declaration knowingly this could amount to a criminal offence for which I could be prosecuted. I understand the Home Aid team of East Ayrshire Council will make relevant enquiries with other Council departments and external agencies such as my bank and building society, in order to request information to verify the details on my application for financial assistance. I consent to other Council departments sharing information held by them to aid my application and hereby authorise East Ayrshire Council to make further enquiries with external agencies which are necessary in order to verify the information provided by me in connection with my application. Signed Applicant Date Print Name Signed Applicant Date Print Name 10

11 Addtional Information Use the space below to provide any further information in support of this application. Please reference question numbers. 11

12 This document is also available, on request, in braille, large print or recorded on to tape, and can be translated into Chinese, Punjabi, Urdu, Gaelic and Polish. Ma tha sibh airson fiosrachadh fhaighinn ann an cànan sam bith eile, cuiribh brath thugainnaig an t-seòladh a leanas. Designed and produced by East Ayrshire Council Design Section 2010 JB/02/10BB Dokument dost pny jest równie w alfabecie Braille a, w wersji z powi kszonym drukiem lub w formie nagrania d wi kowego na kasecie. Na yczenie oferujemy tak e tłumaczenie dokumentu na wybrany j zyk. Housing Services Civic Centre, Kilmarnock KA1 1HW Tel: or homeaid@east-ayshire.gov.uk