Local Council Tax Support and Housing Benefit Claim Form Don t delay - claim today!

2014/15 Local Council Tax Support and Housing Benefit Claim Form Don t delay - claim today! Please return this form as quickly as possible, even if do not have everything we ask for. can send rest to us later. Filling in form Use blue or black ink to fill in form. Do not use pencil. If make a mistake, just cross it out and put right answer next to it. Do not use correction fluid or tape. Please initial any alterations. Answer or questions by ticking relevant box. If are picking an answer from a list of answers, put a tick in relevant box. Do not put a cross in any boxes. If answer a question with a cross or do not answer a question we will have to send form back, and this will delay claim. If someone else fills in form for, re is a special space for m to sign in Part 15. must sign Part 15 as well. Please send form back to us straight away to make sure do not lose any benefit. r benefit will normally start from Monday after we receive form. In form, we ask for proof of r income, rent and so on. If don t yet have all proof we need, send form in now and send proof later. For Council Tax Support claims, we will automatically treat r claim as being made 3 months prior to receipt of form (as long as were liable to pay council tax) if do not want r claim to be assessed for this earlier period tick this box have one month from date we receive form to send in proof. must tell us immediately if r circumstances change. See page 2 for a list of changes that may affect r claim. Please return form eir by post to: Benefits Service, Broxbourne Council, Bishops' College, Churchgate, Cheshunt, Hertfordshire EN8 9XG Or in person by visiting Benefits Service at Bishops College, Churchgate, Cheshunt, Herts, EN8 9XG. Monday to Thursday 8.30am-5.30pm Friday 8.30-5.00pm Or in person to any of Borough One Stop Shops: Cheshunt Wolsey Hall, Windmill Lane, Cheshunt, Herts, EN8 9AA. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm Hoddesdon Library 98a High Street, Hoddesdon, Herts, EN11 8HD. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm Waltham Cross 123 High Street, Waltham Cross, Herts, EN8 0BJ. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm Phone: 01992 785503. Email: benefits@broxbourne.gov.uk www.broxbourne.gov.uk To receive relevant e-communications from Council, please register at: www.broxbourne.gov.uk/emailalerts E-communications are emails that provide information about Council services and events. All information supplied will be processed and held in accordance with Data Protection regulations Date of first contact: Date Received HB Ref. :

tes for filling in claim form About this form This Local Council Tax Support and Housing Benefit claim form has been specially designed to be easy to fill in. It is long, but we have to ask a lot of questions to make sure that everyone who claims gets right amount of award. may not have to fill in all parts of form, but must fill in any part that is relevant to. part starts with a question to help decide if need to fill in that part. Please ensure tick yes or no to each question, do not leave se blank. Evidence We need to see evidence of some of things tell us about. The checklist at end of form will help. If are not sure if we need to see evidence of something, get in touch with us. We will tell what we need to see. We cannot pay r award until we have seen evidence we have asked for. we collect and use information We will use information give in this form, and in any supporting evidence send us, to process r claim for Council Tax Support and Housing Benefit. This authority is under a duty to protect public funds it administers, and to this end may use information have provided on this form for prevention and detection of fraud. It may also share this information with or bodies responsible for auditing or administering public funds for se purposes. For furr information, see www.broxbourne.gov.uk/resident/privacy-policy or contact Council s Data Protection Officer on 01992 785577. If we award Council Tax Support or Housing Benefit If we decide to make an award, we will review r claim regularly. This may involve an unannounced visit to r home by our Visiting Officer. We may also post a form that should complete and return to us with all relevant supporting evidence. Changes must tell us about Tell Council's Benefit Department straight away if; any of r children leave school or leave home; or anyone moves in or out of r home (including lodgers, joint tenants and subtenants); or r income or income of anyone living with, including benefits, changes; or r capital, savings or investments change; or or anyone living with becomes a student; goes on an Apprenticeship Scheme; goes into hospital or a nursing home; goes into prison; or gets, changes or leaves a job; or or r partner are going to be away from home for more than a month; or receive any decision from Home Office; or anything have told us about changes; or move house; or or any one in r household receives or ceases to recieve DLA or PIP. If don t tell us about se changes, may lose money are entitled to or may get too much award. must make sure that tell us about se changes. Don t rely on someone else to pass on message. It is an offence not to tell us about any change of circumstance that affects r award. We may take court action against. If we pay too much support, in most cases, will have to pay it back.

Council Tax Support and Housing Benefit Claim Form page 3 Part 1 About and r partner Do have a partner who normally lives with? A partner means a person are married to or have a civil partnership with, or a person live with as if were ir husband, wife or civil partner. (A civil partnership is a formal arrangement that gives same-sex partners same legal status as a married couple.) Even if r partner only comes home at weekends, or part of week, must include m Surname or family name First name(s) Any or surnames or family names have used, such as before marriage or in a previous marriage Title (Mr, Mrs, Ms and so on) Address Do not tell us r partner s address if it is same as rs. If have a partner, must answer all questions about m, as well as rself. r partner What date did move in to this address? (first spent night re) r daytime phone number do not have to tell us this, but it may help us to deal with r claim more quickly. What is this number? Please tick. E-mail address We want to deal with r claim as quickly as we can and if we have r e-mail address we may contact this way. Date of birth National Insurance number can find this on payslips or letters from Department of Works and Pensions or tax office. We can decide r claim only if we see evidence that this is r National Insurance number (see part 13). Home Work Mobile Textphone Home Work Mobile Textphone Letters Numbers Letter Letters Numbers Letter If do not have a National Insurance number, or cannot find it, tick this box.? If r partner does not have a National Insurance number, or cannot find it, tick this box. We must see evidence of and r partner s identity and National Insurance number. If or r partner are asylum seekers, must provide r current Home Office letter. Read checklist in part 17.?

Part 1 About and r partner continued page 4 Are living away from home at moment? Tell us why are not living at home. When did last live at home? When do expect to go back home? Tell us address where are living at moment. If r home has been sublet, tell us who lives re now. Have or r partner claimed Council Tax Support, Housing Benefit or Council Tax Benefit before? r partner When did claim? When did y claim? Which council did claim from? Which council did y claim from? What name did claim in? What name did y claim in? What address did claim for? What address did y claim for? If have moved home in last 12 months, tell us r last address. Were home owner, a private tenant, a council tenant or a boarder at this address? Have or r partner come to live in England, rrn Ireland, Scotland, Wales, Republic of Ireland, Channel Islands or Isle of Man in last 2 years? We will write to about this. We will write to about this. What is r nationality? If r nationality is not British, on what date did last enter UK? The UK is England, rrn Ireland, Scotland and Wales.

Part 1 About and r partner continued page 5 Are or r partner in hospital at moment? When did go in? When will come out (if know this)? Do or r partner get Disability Living Allowance? r partner When did y go in? When will y come out (if y know this)? Do or r partner get Personal Independence Payment? Do or r partner get Attendance Allowance? Does anyone get Carer s Allowance for looking after or r partner? (If anyone claims Carer s Allowance for looking after in future please let us know) Have or r partner ever claimed Carer s Allowance? Still tick if claimed but were not paid any money. Are or r partner a student? We need to see r current student certificate and all pages of r student finance/bursary award letters. Tick if or r partner are: Do study full time or part time? Do y study full time or part time? Full time Part time Full time Part time an apprentice in legal custody severely mentally impaired registered blind long-term sick or disabled Is anyone in household pregnant? If, who? Due Date

Part 2 About children page 6 Are re any children in r household? By children we mean under 16 or aged 16 to 20 and in full-time education or approved training. Go to Part 3. If re are more than 4 children, use a separate sheet of paper to tell us all information we ask for on this page. If are sending a separate sheet of paper, tick this box. Part 2 About children - continued page 6 Surname or family name First name(s) First child Second child Third child Fourth child Date of birth What is child s sex? The child s relationship to The child s relationship to r partner Usual address if different from rs Child Benefit number Who gets Child Benefit for m? We need to see proof of this. Is child registered blind? Does child get Disability Living Allowance? First child Second child Third child Fourth child Does this child get Personal Independent Payment? Do pay a registered childminder, nursery or after-school club any childminding costs for this child? If yes, please tell us If yes, please tell us If yes, please tell us If yes, please tell us name and registration name and registration name and registration name and registration number of childcare number of childcare number of childcare number of childcare provider. provider. provider. provider. much do pay a week? much do pay a week? much do pay a week? much do pay a week?

Part 3 About or people who live with page 7 Do any adults usually live Go to Part 4. with and any partner have? Answer all questions in this section. By adults we mean people over 16 who nobody gets Child Benefit for. Do not tell us about people who just share a hall, bathroom or toilet with. If want to tell us about more than 3 people, use a separate sheet of paper. If are sending a separate sheet of paper, tick this box. Surname or family name Or names First person Second person Third person Date of birth National insurance Number Their relationship to or r partner Some examples are aunt, bror, daughter, far, grandson, grandmor, stepdaughter, joint tenant, joint owner, subtenant, lodger or friend. When did y move in? Do y receive any State Benefits? Tell us which. Tell us which. Tell us which. Do y normally work? Please tell us ir gross earnings Please tell us ir gross earnings Please tell us ir gross earnings Are y a full-time student, a student nurse, a care worker or an apprentice? Tell us which. Tell us which. Tell us which. Are y severely mentally impaired? Are y in legal custody at moment? When are y expected to be released? When are y expected to be released? When are y expected to be released? Are y in hospital at moment? Are any of people who live with married to each or, civil partners of each or, or living toger as if y are married or civil partners? When did y go in? When did y go in? When did y go in? When will y come out (if know this)? When will y come out (if know this)? When will y come out (if know this)? Tell us ir names. And is partner of is partner of

Part 4 About Income Support, income-based Jobseeker s Allowance, Pension Credit (Guaranteed Credit) and Employment and Support Allowance (income-related) r partner Are or r partner getting Income Support, income based Jobseeker's Allowance, Pension When did start When did y start Credit (Guarantee Credit) or getting it? getting it? Employment and Support Allowance (income related) at moment? Are or r partner still waiting to hear about a claim for Income Support, income-based Jobseeker s Allowance, Pension When did claim? When did y claim? Credit (Guarantee Credit) or Employment and Support Allowance (income-related)? Part 5 About benefits, tax credits and state pensions Are or r partner getting any of benefits or credits listed below, or are waiting to hear about benefits or credits have Go to Part 6. claimed? Read list of benefits and credits below and tell us about any that or r partner are getting now or have claimed. Tell us about benefits below. r partner much often much often Pensions do get? is it paid? do y get? is it paid? page 8 State Retirement Pension Pension Credit (Savings Credit) Widow s Allowance or Bereavement Allowance Widowed Parent s Allowance or Widow s Pension War Widow s or War Dependant s Pension War Disablement Pension Industrial Injury/Disablement Pension Exceptionally Severe Disablement Allowance Benefits and Allowances Contribution-based Job Seeker s Allowance Child Tax Credit Working Tax Credit Child Benefit Employment and Support Allowance - contribution based Attendance Allowance Disability Living Allowance: Mobility Component Care Component Incapacity Benefit

page 9 Part 5 About benefits, tax tax credits and and state state pensions pensions Are or r partner getting any of benefits or credits listed r below, or are waiting to hear about benefits or credits have partner Go to Part 6. Personal claimed? Independence Read list Payment of benefits and credits below and tell us about Carer s any that Allowance or r partner are getting now or have claimed. Tell us about benefits below. Severe Disablement Allowance Maternity Allowance r partner Fostering Allowance much often much often Universal Pensions Credit do get? is it paid? do y get? is it paid? Any State or Retirement benefit, Pension pension or money Pension from Credit (Savings government Credit) Are Widow s repaying Allowance a Social or Fund Bereavement Allowance loan or overpayment for any of If yes, which one? se Widowed benefits? Parent s Allowance or Have Widow s or Pension r partner If yes, please give details War deferred Widow s (put or off) War receiving a Dependant s pension? Pension War Part Disablement 6 Income Pension or than earnings Industrial Do or Injury/Disablement r partner have any money coming in (or expect to Go to Part 7. Pension have some money coming in) that have not already told us Exceptionally Severe Complete questions as below. about this form? Disablement do not need Allowance to tell us about payments from Independent Benefits Living Fund, and Allowances Eileen Trust or Macfarlane Trust. Contribution-based Job r partner Seeker s Allowance much often much often Private Pension 1 paid by Child Tax Credit do get? is it paid? do y get? is it paid? Working Tax Credit Child Private Benefit Pension 2 paid by Date of next increase Date of next increase Incapacity Benefit Please attach separate sheet if have more than 2 pensions Employment and Support Date of Allowance - contribution based next increase Date of next increase Pension Protection Fund Attendance Payments Allowance Disability AnnuitiesLiving Allowance: Maintenance Mobility Component for Care Component Maintenance for r child - including CSA Student grant or loan Payments from boarders Weekly amount from letting or sub-letting part of a property Payments from a charity Any or income e.g. Redundancy or Loan Protection Payments (please give name) We must see evidence of any money or pension coming in before we can decide how much Support can get. Read checklist at Part 17 to see what can use as evidence.

Part 7 About working for an employer Do or r partner work for an employer? Do work for more than one employer? What kind of work do do? Go to Part 8. r partner Go to Part 8. Answer questions in this section. Answer questions in this section. Tell us about all employers on a separate sheet of paper and send it with this form. Include all information asked for below. If are sending a separate sheet of paper, tick this box. page 10 Part 7 About working for an employer - continued page 12 What is r employer s name and address? r partner When did start this job? much do get paid before tax and National Insurance are taken off? often do get paid? are paid? For example, in cash, by cheque or straight into a bank or building society account. many hours a week do usually work? Give details of any regular overtime, bonuses, commission or tips. Are getting Sick Pay, Maternity Pay, Paternity Pay or Adoption Pay from r employer at moment? When did it start? Do pay into a private or company pension scheme? much? much? often? often? We must see 5 weekly, 3 fortnightly or 2 monthly consecutive pay slips before we can decide how much Support can get. Read checklist at Part 17 to see what can use as evidence.

Part 8 About being self-employed page 11 Are or r partner self-employed? Go to Part 9. r partner Go to Part 9. Answer questions Answer questions on this page. on this page. must send us r trading accounts for last financial year. If have only recently set up business and do not have a full year s accounts, we will need to see some or evidence of r income. We will write to about this. Part 8 About being self-employed - continued page 12 page 12 What What kind kind of of work work do do do? do? r partner When When did did business business start? start? What What is is business business address? address? Are Are a Director Director of of business? business? Are Are re re any any or or partners partners in in business? business? Tell Tell us us ir ir name name and and address. address. Tell Tell us us ir ir name name and and address. address. many many hours hours a week week do do usually usually work? work? Do Do get get a Business Business Start-up Start-up Allowance? Allowance? often? often? much? much? much? much? often? often? Do Do pay pay into into a private private pension pension scheme? scheme? often? often? much? much? often? often? much? much? We We must must see see evidence evidence of of r r earnings earnings before before we we can can decide decide how how much much Support Support can can get. get. Read Read checklist checklist at at Part Part 17 17 to to see see what what can can use use as as evidence. evidence.

Part 9 About any or work Do or r partner do Go to Part 10. any or work? This could be voluntary work, Answer questions on rapeutic work or any or this page. work. Part 9 What or work do do? About any or work - continued r partner Go to Part 10. Answer questions on this page. r partner page 12 page 13 What is name and address of person do this work for? When did start this work? many hours a week do usually work? Do get paid for this work? much? much? often? often? We must see evidence of any earnings before we can decide how much Support can get. Read checklist at Part 17 to see what can use as evidence. Part 10 About bank accounts, savings, investments and property r partner Do or r partner have any bank accounts, savings, property Go to part 11 or investments in UK or abroad? Answer all questions in this part. This includes cash, current accounts and savings accounts with a bank or building society, post office accounts, Premium Bonds, National Savings Certificates, stocks, shares and property. Please answer se questions for rself and r partner. Please include empty and overdrawn accounts, wher in one name or jointly held with anyone else. r Partner's Account number/name/or details balance/value balance/value Do have bank, building society or post office accounts? (including current accounts) If yes, please give details. We must see evidence of all capital, savings and Name investments. Read checklist at Part Number 17 to held see what can use as evidence. We will need statements or passbooks covering last 2 months at least, even if balance is Do overdrawn. have stocks, shares, unit trusts?

Part 10 About bank accounts, savings, investments and property Name r partner Do or r partner have any Do bank accounts, have stocks, savings, shares, property Go to part 11 unit or investments trusts? in UK or abroad? Answer all questions in this part. If yes, list names of This includes cash, current accounts and savings accounts with a bank or building society, post office accounts, investments and number of shares Premium held. Bonds, National Savings Certificates, stocks, shares and property. Part 10 About bank accounts, savings, investments and property - continued Do have National Savings Certificates? If Do yes, list have National issue, purchase date Savings and Certificates? number of units. If yes, list issue, purchase date and number of units. Number held page 13 page 14 Do have or investments, redundancy payments, premium bonds, Tessas, ISAs, SAYE, cash etc? If yes, please give details. (Please also use this space if need to tell us more about any of above savings.) Have or r partner received any backdated benefit or deferred payments, such as State pension, which have added to r savings? If please give details. Do or r partner own or partly own any property or land except home live in, eir in UK or abroad? Tick, even if have a mortgage or loan for property or land. This includes jointly owned properties. What is address? much i s it worth? If have a mortgage or loan for this, how much is left to repay? Have or r partner received a compensation payment relating to Second World War?

Part 11 About rent page 14 Do rent r home? Tick if would pay rent but already get Housing Benefit. much is rent for r home? May we discuss progress of r claim with r landlord/agent? We will not disclose personal/income information. Go to Part 15. Answer all questions in this section. every (For example, every week/fortnight/4 weeks/month.) What date did r tenancy start? What date did move in? Please sign here. I authorise Council to discuss progress of my claim with my landlord/agent. Signed Date What is r landlord s name and address? By landlord we mean person or organisation who owns property live in. If r landlord has an agent, tell us ir full name and address. By agent we mean person or organisation actually pay r rent to. Are, r partner, or any of r or r partner s children related to r landlord or agent, or to r landlord s partner or agent s partner? What is relationship? is my landlord s or agent s Related includes related through marriage, even if marriage has ended. Some examples are ex-wife, ex-husband, aunt, bror, daughter, far, grandson, grandmor, son-in-law or stepdaughter. Are or r partner a director, shareholder or employee of r landlord? Have or r partner owned r current home in last 5 years? Does anyone else share rent with and r partner? Tell us ir names and ir relationship to and r partner. much of rent do pay? every (For example, every week/fortnight/4 weeks/month.)

Part 11 About rent continued page 15 Who is liable for council tax at this address? Has r rent been registered as a fair rent by a rent officer? Are re any weeks when do not have to pay rent? many in a year? Are behind with r rent? By how many weeks? Does r rent include money for following? Meals Which meals are included? All Breakfast Evening Water authority charges Heating Lighting Hot water Fuel for cooking What is it? Is anything included or separate from r rent that have not already told us about? Please tick to show if property is let as: furnished partly furnished minimally furnished unfurnished This means completely furnished. This means some furniture, but not all. This means just two or three items. This means no furniture at all. Part 12 About where live What sort of building do live in? Tick one box only. Detached house Or (please say what) a Flat in a house Caravan, mobile home or houseboat Semi-detached house Flat in a block Board and lodgings Terraced house Flat over a shop Hotel Maisonette Bedsit or rooms Residential nursing home Bungalow Hostel Residential care home Detached Bungalow Ground rent

Part 12 About where live - continued page 16 Part 5 About where live continued page 14 many rooms are re in building? Living rooms Bedsitting rooms Bedrooms Bathrooms or shower rooms Separate toilets Kitchens Or rooms In whole Just for and That share with building? r household? or people? What are se or rooms? Do have a bedroom which is used overnight by someone who cares for or r partner but does not live at r address? Their name and address Do use r home for business purposes? Do have a main home somewhere else? If r main home is somewhere else in UK or abroad, tick, even if do not pay rent for it. What is address? Part 413 About Backdating Income Support, income-based Jobseeker s Allowance, Pension Credit (Guaranteed Credit) and Employment and Support Allowance (income-related) We can usually award benefit from Monday after day we get r claim. Sometimes, we can pay Housing Benefit from an earlier date if have a good reason for not claiming earlier. If want us to consider paying r Housing Benefit from an earlier date, tell us when want Housing Benefit from and why did not claim before, in box below. If are a working age customer, can request r claim to be backdated for up to 26 weeks from date r we partner receive form. Are Tell us or date r partner want getting to Income claim housing Support, benefit income frombased Jobseeker's Allowance, Pension When did start When did y start Credit (Guarantee Credit) or getting it? getting it? Employment and Support Allowance (income related) at moment? Are or r partner still waiting to hear about a claim for Income Support, income-based Jobseeker s Allowance, Pension When did claim? When did y claim? Credit (Guarantee Credit) or Employment and Support Allowance (income-related)?

Part 14 will be paid and choices have page 17 We will write to about r benefit award. Enter r email address if want to be contacted in this way If pay rent to a private landlord we will pay any benefit directly to. If feel this will cause difficulties, please call 01992 785503 for advice. If pay rent to a Housing Association can eir have r housing benefit paid to or direct to r landlord. Please tick how would like to be paid To myself To my landlord If rent from a registered social landlord we can pay r benefit directly to m. Orwise we will pay r Housing Benefit direct into a bank or building society account by Bank Automated Credit (BAC S). If are awarded Local Council Tax Support, we will pay this into r Council Tax Account. If do not have a bank or building society account must set one up. can get advice about opening and running a bank or building society account from any bank or building society of r choice. If have any difficulities in opening one of se accounts please contact us on 01992 785503 for advice. Under Local Housing Allowance Scheme will have r Housing Benefit paid directly to (unless are considered by us to have difficulty in managing r financial affairs). will be informed in writing when this will take effect. We can only pay Housing Benefit into accounts in r name. Please note we are unable to pay direct payments into r partner s account unless it is a joint account with, also we cannot pay direct payments into a Post Office Account. Please remember it is r responsibility to pay r landlord. To accept direct payments of Housing Benefit into r account please complete following: Name and address of bank Account number Sort code Roll. Account Name Full Name (in CAPITAL LETTERS) r Signature Date

Part 15 Anything else need to tell us Use box below to tell us anything else think we should know about. Use a separate sheet of paper and attach it to this form if need to. If are sending separate sheets of paper with this form, tell us how many. page 18 Part 16 Declaration page 19 Part 16 Declaration page 19 Even if someone else has partly or fully filled in this form for, MUST sign this declaration if can. If have a partner, it would be helpful if y sign below to confirm that all details about m are correct. Please read this declaration carefully before sign and date it. I understand following: If I give information that is incorrect or incomplete, may take action against me. This may include court action. will use information I have provided to process my claim for Local Council Tax Support and Housing Benefit, or to assess any discount or grant for Council services. may check information with or sources as law allows. may use any information I have provided for this and any or claim for social security benefits that I have made or may make. This includes any Discretionary Housing Payment. may give some information to or government organisations, such as government departments and local councils, if law allows this. I know I must let Council's Benefit Department know immediately in writing about any change in my circumstances or circumstances of anyone living with me, which might affect my claim. If I do not, may take action against me This may include court action. I declare that this is my claim for Local Council Tax Support and Housing Benefit and information I have given on this form is correct and complete. I authorise Council to make any necessary enquiries to check that information is true and correct. I have read and understood this declaration, and my responsibilities in reporting any changes in my circumstances to Council. Signature of person claiming Date Partner s signature Date Signature of Date person claiming If this form has been partly or fully filled in by someone who is not person claiming, please tell us why are Partner s filling in this form for person claiming. signature Date If this form has been partly or fully filled in by someone who is not person claiming, please tell us why are filling in this form for person claiming. As far as possible, I have confirmed with person claiming that answers I have written on this form are correct. If I am making this claim on behalf of above person, I understand that I am liable for what I have written on form and accept that declaration applies to me. As Name far as of possible, person I have who confirmed filled in with form person claiming Signature that of answers person I have written on this form are correct. If I am making this claim on behalf of above person, I understand that I am liable for what I have written on form and accept that declaration applies to me. Relationship to person claiming Name of person who filled in form Signature of person Date

Contact us In person for benefit enquiries and handing in claim forms or evidence: By phone: By writing to: By e-mail: Cheshunt Wolsey Hall, Windmill Lane, Cheshunt, Herts, EN8 9AA. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm Hoddesdon Library 98a High Street, Hoddesdon, Herts, EN11 8HD. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm Waltham Cross 123 High Street, Waltham Cross, Herts, EN8 0BJ. Monday to Friday 9am - 5.30pm. Saturday 9am - 1pm 01992 785503 Benefits Service, Broxbourne Council, Bishops' College, Churchgate, Cheshunt, Hertfordshire EN8 9XG Monday to Thursday 8.30am-5.30pm Friday 8.30-5.00pm benefits@broxbourne.gov.uk page 19 If know or suspect someone is committing benefit fraud, can report m direct without having to give r name or details by: writing to address above; phoning: 01992 785514 - or National Hotline number 0800 854 440; e-mailing to benefits@broxbourne.gov.uk; or going on our website: www.broxbourne.gov.uk Part 17 Checklist Please tick to tell us what evidence are sending with this form. We must see original documents, not copies. If bring m to our Office, we will take details we need and give documents back straight away. If do not provide all evidence we need, we might not be able to pay any support. We need same evidence for r partner, if have one, and for any or adults living in r home. If cannot send evidence we need at moment, send form back to us now and send evidence later. We can start to process r claim, but we will not be able to pay any benefit until we have all evidence. Please tell us now in Part 15 if cannot supply evidence within one month. Evidence of identity Such as a birth certificate, marriage certificate, passport, National Insurance number card, medical card, driving licence, UK residence permit, current Home Office letter, EU identity card or recent gas or electricity bill. We may need to see several of se documents for each person. Evidence of National Insurance number Such as a National Insurance number card, payslips or letters from social security or tax office. Evidence of savings, investments and property Such as all r bank, building society or post office books, full bank statements, or certificates for premium bonds, National Savings Certificates, ISAs, Tessas, stocks, shares and unit trusts. The evidence send must show details for at least last 2 months. Evidence of earnings - For, r partner and any or adults resident This means r last 5 payslips if are paid every week, r last 3 payslips if are paid every 2 weeks, or r last 2 payslips if are paid every month. We can send a form to r employer to fill in if do not have se payslips. If or r partner are self-employed, we need to see r accounts for last financial year or, if have been trading for less than 6 months, a summary of r trading records so far. We can supply a form on request. We need proof of all expenses and income by providing all receipts and invoices solely relating to r self employment. Do not send us Income Tax self assessments as se are not acceptable as proof for benefit purposes. Evidence of or income Such as pension slips from a former employer or a letter from court showing how much maintenance are getting. We need to see evidence of any money people pay for board and lodgings. Evidence of benefits, allowances, tax credits, pension credits or pensions, for, r partner and any or adults resident Such as current award notices or letters from Department for Work and Pensions confirming how much get. If do not have evidence, let us know straight away. Evidence of or money paid out Such as letters about student grants or maintenance, letter from OFSTED registered childcare provider, confirming hours and charge per hour for childcare for each child. We also need to know if childcare changes between term time and school holidays, if so please also provide confirmation of this. Evidence of private rent and tenancy Such as rent book, rent receipts, full tenancy agreement or a letter from Landlord. This must include full name and residential address of Landlord and or Landlord s Agent, date agreement started, rental amount, any services included in rent, how often rent is due, r name and address.

Part 18 Ethnic Background The government has asked us to gar information about our customer s ethnic background. It s r choice wher to fill in this section. Please show which of following groups and r partner (if any) consider belong to by ticking one box for and one for r partner. White r partner Asian r partner British Asian British Irish Bangladeshi Or white Indian Kashmiri Mixed Pakistani White and black Caribbean Or Asian White and black African White and Asian Black Or mixed Black British Caribbean Chinese African Or black Or Anything else want io tell about that may affect r claim