Deferred Payment Scheme Application Form

Deferred Payment Scheme Application Form

How to complete this application form You will need to fully complete the form starting on page three of this booklet. Please ensure you have read the leaflet Information on Deferred Payment Scheme available on leeds.gov.uk/deferredpayments, to ensure you meet the criteria for the scheme. We will also need to see original documents to help with your application. (See Section 7) We will need to verify the documents outlined in Section 7 in two ways: 1. From a Leeds City Council member of staff. To book an appointment, please call 0113 247 8867. We will photocopy your original documents. 2. If this is not convenient, we require a professional individual (employer or solicitor) to confirm who you are and that they have seen the original documentation. The application and copies of your documentation can then be forwarded to: Financial Management Adult Social Care Finance Community Care 4 th Floor West Civic Hall Leeds LS1 1UR For enquires about this form, or the deferred payment scheme please call, 0113 247 8867 2

Section 1 Details of the person applying for the Deferred Payments Scheme (the person in care) ESCR Number (Local Authority Unique Ref No. to be quoted on all correspondence) Title (e.g. Mr, Mrs, Ms) First Name(s) Last Name Date of Birth Address (including postcode) Email Telephone number Are you: Single Married Divorced Separated Widowed Civil partnership Section 2 Details of representative of person applying for the Deferred Payments Scheme (if applicable) Title First Name(s) Last Name Address (including postcode) Telephone Email 3

Relationship to person named above Do you have legal authority to act on behalf of the person named in Section 1? Yes No If yes, please give details: Power of Attorney Enduring of Lasting Power of Attorney Deputy or receiver Solicitor Please attach documents confirming legal arrangements Section 3 About the property Please give the full address of the property (including postcode) What is the property s current value? Do you have a mortgage or other secured loan on the property? Yes No If yes, what type of mortgage or loan do you have? Repayment Endowment Interest Only If you have another type of loan please give details: How much do you pay each month (include any endowment or insurance premium) Name of mortgage lender Account number Date of mortgage agreement Amount of outstanding mortgage Consent form to enable contact with mortgage provider 4

Please attach documents confirming mortgage details Does anyone else have an interest in the property with you? Yes No If yes is this part of an equity release scheme? (you will be required to provide documentation to verify this) Yes No If yes, please give their details and their interest: Name Address Interest in property Please attach documents confirming details What type of property is it? Detached house Terraced house Flat Semi-detached house Bungalow Other If other, please give details: Does anyone live in the property? Yes No If yes, please give details: 5

Section 4 About the property expenses Type of Expense How much? How often? (Weekly, monthly, yearly) Service Charge Fuel Charge Ground Rent Building Insurance this is essential Other charges Please attach documents confirming expenses Section 5 Property Maintenance You will need to maintain the property and land, including gardens and outbuildings. This means the property will need to be insured annually and utility bills will need to be paid. It may also include renting the property out. Please explain how do you intend to maintain and upkeep the property, including whether you plan to rent it out. 6

Section 6 Other information (any other relevant information) 7

Section 7 Checklist for Documentation Please check and ensure you have provided documentation requested on this form. Details of legal representative (Please provide Enduring/ Lasting Power of Attorney or letter from Office of Public Guardian detailing who has been appointed as Deputy for service user) Joint or other interests in the property Copy of equity release agreement (if appropriate) Land Registry or title deeds 3rd Party Top Up declaration (if appropriate) Death certificate for a named deceased party on land registry or title deeds Property expenses including Building Insurance Photo identification Mortgage details and consent form Property Valuation Please remember, original documentation verification is required. Please call 0113 2478867 to arrange for appointment or alternative certification. If you have already provided the above documents to a Finance Officer from Community Care Finance, you will not need to provide these again. 8

Section 9 Declaration I wish to make an application under the Deferred Payments Scheme. I understand that acceptance of any application under the scheme is at the discretion of Leeds City Council, subject to you meeting the eligibility criteria and the local authority being able to obtain adequate security. The deferred payments will not take effect until a formal agreement is entered into. I confirm that I own /part-own (please delete as appropriate) the property specified in Section 3. I authorise Leeds City Council to check legal title to the property. When the agreement begins, I agree to a legal charge being placed on the property specified in Section 3 and agree to pay the legal costs of Leeds City Council. I agree that I shall be responsible for payment of the weekly contribution to the cost of my care that I am assessed to make under the regulations specified in the Care Act 2014 regulations regarding charging from my income and other capital I confirm that I and all other persons who occupy or have an interest in the property specified in Section 3 have been told of the need to take independent legal and financial advice before I enter into an agreement under the Deferred Payments Scheme. I confirm that the information given on this form is true and accurate to the best of my knowledge. Leeds City Council will use the information you have provided for the following purpose of deciding on the application for a deferred payment and the financial assessment of the person s contribution. No personal information you have given us will be passed on to third parties for commercial purposes. [Our policy is that all information will be shared among officers and other agencies where the legal framework allows it, if this will help to improve the service you receive and to develop other services.] You have the choice to pay for fees and interest as it accrues throughout the agreement or you can pay at the end and the fees will be added to the debt outstanding. Please note that interest will be added to any debt outstanding. Please indicate below your intention. I wish to pay set up fees on successful application (An invoice will be issued when we have a signed agreement). I wish to pay interest and ongoing fees six monthly (in arrears). (An invoice will be issued with the six monthly statements). I wish for all fees and interest to be accrued with the debt outstanding until the end of the agreement. Your full name: Your signature: Date: If you are signing on behalf of the person applying to use the Deferred Payments Scheme, you must be the person named in Section 2, and have legal authority to act. 9

Leeds City Council For general information about Adult Social Care telephone customer services on 0113 222 4401. June 2015 10