Claim Form for Housing Benefit and Council Tax Support

Claim Form for Housing Benefit and Council Tax Support Name: Address: For office use: Claim reference: Date issued: Date received: Full postcode: You can check if you may be entitled to benefit using our online benefits calculator at www.iichfielddc.gov.uk/benefits Important please read these help notes carefully before you fill in the form. Please make sure that your claim address is stated on the front of this form. If your capital is more than 16,000, you will not be entitled to any Housing Benefit, except if you receive Pension Credit Guarantee. If your capital is more than 6,000, you will not be entitled to Council Tax Support, except if you are receiving Income Support, income based Job Seeker s Allowance or income related Employment Support Allowance or if you are a pensioner. If you have got this form from anyone other than the council, for example, your landlord, you must contact us immediately on 01543 308900 to register the date of your claim. Please answer all the questions completing every box. If you do not, we may return your claim form. When completing this form, please write your answers in the white boxes only. When the questions have and boxes for your answer, clearly tick ( ) one box only. We may need proof of the information you give us. We will tell you what proof we need at the end of each section. All the documents you give us must be original documents. Please supply all the proof with this form. Do not post important or valuable documents, please bring them into the office. We will copy all of the documents and give them back to you. We cannot accept your own photocopies. You must get your claim and all of the proof we need back to the council as soon as possible (no later than one calendar month if you have already registered your claim), if you do not you may lose benefit/support. When we receive your application form, we will send you a receipt. If you do not get a receipt within five working days, contact us immediately. 1

If your circumstances change you must tell the Benefits Section straight away. If you do not tell us promptly, you will be breaking the law and the council may take action against you. Examples of changes in circumstances you must report to Lichfield District Council: you or your partner s Income Support or Jobseeker s Allowance stops you or your partner start work you or your partner have any changes to your income someone joins or leaves your household anyone in your household has a change in income child benefit changes your rent changes you move, or any absence from home likely to last more than 13 weeks your capital changes your child care costs change your tax credits change. If you are in paid employment and your earnings vary from one pay day to the next, we will try to use a figure that most represents what your future earnings will be. This will mean taking an average of your pay. You need to keep the council informed of any fluctuations in your earnings. It would be helpful if you could send your pay slips into the office every three months to ensure that the earnings figure included in your assessment is correct. This will help avoid an overpayment and will ensure you receive the right amount of benefit. If you get Pension Credit, you will usually report changes to the Pensions Service but there are still some changes you must tell us about in writing these are listed on the receipt. Declaration. I have read and understand the help notes. I understand I must report any changes in circumstances promptly. Signed... Date... Partner s signature... 1 Type of claim If you are of working age - go to section 2. If you are a pensioner, you may qualify for Second Adult Rebate. This might help you if you are not entitled to Council Tax Support in your own right because of your income. If there is another adult in the household (other than your partner) and they are on a low income, we may be able to work out your benefit using their gross income. I want to claim Second Adult Rebate only If, please put your full name, address, date of birth and National Insurance Number on page 3. You will also need to fill in section 5, starting on page 6. Proof We need to see proof of the second adult s income. This must show their present address, the type of income and how much they receive. We need to see proof of your identity. 2

2 About you and your partner Do you have a partner? This is someone you are married to or live with as a couple, including civil partnerships, same sex couples and partners that work away from home. If, you must also give us details about your partner where we ask for them on the form. You Your partner Title Mr Mrs Miss Ms Mr Mrs Miss Ms Surname First names Date of birth National Insurance Number Marital status Phone number Email address What date did you move into this address? Tell us the names of everyone who owns this property If you have moved within the last 10 years please tell us your previous address Postcode Postcode Did you own your last home? Did you claim Housing Benefit or Council Tax Support at your last address? Proof We need to see proof of your identity and proof of your National Insurance Number. If you have a partner, we also need to see proof of their National Insurance Number. This proof must be at least two official documents that confirm who you and your partner are. 3

2 About you and your partner continued Are you a care leaver under the age of 22? Are you or your partner registered blind? Is anyone getting Carer s Allowance for looking after you or your partner? If, give their full name and address What date did you come to live in the UK? If, what is your nationality? Have you come to live in the UK under a sponsorship undertaking? Have you applied for asylum? 3 About your joint tenant Are you a joint tenant? If, please give details below. Please give the names of all joint tenants If, please go to section 4. Surname 1st person 2nd person 3rd person 4th person First name Male or female Relationship to you If any of the above are partners, please tell us who they are Do they live in the property? 4

4 About any children Do you have any children who live with you? If '', please give details below. Only give details of children you receive Child Benefit for. If you have more than 4 children please continue on a separate page. If, please go to section 5. Surname 1st child 2nd child 3rd child 4th child First name Relationship to you (for example son or daughter) Date of birth Are they registered blind? Are they getting Disability Living Allowance or Personal Independance Payments? Are they in full time education? If and they will be leaving in the next 12 months please tell us when Do you pay a registered child minder/ after school club or day nursery to look after any of your children? If, please give details below. If, please go to Proof below. If, how much do you pay? How often do you pay this? Please give the names of the children you pay this for Do you receive a grant towards your childcare costs? Proof We need to see proof that you are getting Child Benefit, Disability Living Allowance or Personal Independance Payments (if applicable). You must provide birth certificates for children under age of 5. If you pay for childcare, please send a letter from the child minder or nursery confirming the amount you pay. This should give their registration number. If you receive a grant, we need to see proof of the amount you get. 5

5 About any other people living in your home Does anyone else live in your home? If, please give details below. If there are more than 4 people please continue on a separate sheet. If, please go to section 6. You must tell us about everyone else who lives in your home. 1st person 2nd person 3rd person 4th person Surname First name National Insurance Number Relationship to you (for example son, daughter, tenant) Date of birth If any of the above are partners, please tell us who they are If any of these people are boarders or tenants please go to section 14 and tell us about the amount they pay you. If they are not boarders or tenants, please complete the rest of this section. Do they work? Number of hours worked each week Weekly pay before any stoppages Do they get Income Support, Jobseeker s Allowance or Employment Support Allowance? Do they get Pension Credit? Are they a student? If, we need to see the enrolment certificate. Are they an apprentice? Are they a carer? 6

5 About any other people living in your home continued Are they severely mentally impaired? 1st person 2nd person 3rd person 4th person Do they receive any other income? If, what is it? How much do they receive each week? Proof We need to see proof of the income of everyone you have listed in section 5, except tenants and boarders. If they are working, this proof should be their last five payslips if they are paid weekly, their last two payslips if they are paid monthly, or their last three payslips if they are paid fortnightly. If they are getting a benefit, we need to see a recent letter from the Department for Work and Pensions, the Job Centre or the Pensions Service. 6 Students By student we mean someone who is in further or higher education. Are you or your partner (if you have one) students? If, please give details below. Is your course full time (usually more than 16 hours) or part-time? Value of any grant or loan You Your partner Value of any money paid by parents or deed of covenant Date academic year starts Date academic year ends Please give the name and type of course you are following Proof We need to see the original grant or loan award notice and evidence of the hours of study. 7

7 About your work Do you or your partner work? Please include voluntary, temporary or unpaid work If, what date did you last work If, give details below. If you are self-employed go to section 8. What date did you start? Job title (including company directors) Name and address of employer Employer s phone number Number of hours you work each week Your payroll number Average pay before tax How often are you paid? (for example weekly, 4 weekly, calendar monthly) How are you paid? (for example cash, cheque, straight into bank) Do you get any bonuses, overtime, commission or tips? If, how often do you get them? How much do you get? When is your next pay rise due? Do you or your partner have more than one job? If, please give details on a separate sheet. If you pay into a private pension scheme and the payment does not come out of your wages, please provide evidence of your payments. Proof We need to see your last five payslips, if you are paid weekly, your last three if you are paid fortnightly, or your last two if you are paid monthly. The payslips must show your employer s name, the number of hours worked and the period covered, gross pay for the year to date, gross pay for the pay period and any deductions for income tax, national insurance and pension contributions. If you do not get payslips or have handwritten payslips, please contact us for an employment certificate. 8

8 About your self-employment Are you or your partner self-employed If, give details below. When did your business start? What is the nature of your selfemployed trade or business? You Your partner Name and address of the business How many hours do you work? What do you estimate your weekly net profit to be? Are you a partner in the business? If, please give the names of the other business partner or partners Do you run your business from your home? Do you or your partner get a Business Start-up Allowance? Do you have a Business Account? If, when did it start? Do you also work for someone else? If, what other work do you do? If you pay into a private pension scheme please provide evidence of your payments. Proof We need you to complete a self-employed questionnaire form, which we will provide on receipt of your claim. We need to see your latest audited accounts. If you do not have any accounts, send us a summary of your book keeping records for the last twelve months with your receipts. If you or your partner are company directors, please tell us in section 14 Other Information on page 17. 9

9 Income Support About other income (but not your earnings) Tell us if you receive any of the income listed in this section. You must answer every question. If you do not, we may need to return the form to you. You Your partner How much How often How much How often Jobseeker s Allowance Employment Support Allowance Employment Training Allowance Universal Credit Maintenance payments you receive (excluding child maintenance) Child Benefit Child Tax Credit Working Tax Credit State Retirement Pension Bereavement Benefit Pension Credit Guarantee Savings Credit Private or works pension (after tax) Annuities/other pension Widow s Allowance or Pension War Widow s or Dependant s Pension War Disablement Pension Attendance Allowance Personal Independence Payments Daily Living Component Personal Independence Payment Mobility Component Disability Living Allowance Mobility component 10

9 About other income (but not your earnings) continued You Your partner Disability Living Allowance Care component How much How often How much How often Statutory Sick Pay Incapacity Benefit Severe Disablement Allowance Industrial Injuries Disablement Benefit Industrial Death Benefit Reduced Earnings Allowance Maternity Allowance/Pay (paid by employer) Statutory Adoption Pay Statutory Paternity Pay Fostering Allowance Adoption or Custodianship Allowance Payment from boarders Rent received from letting or sub-letting a property Payments from a mortgage protection policy Carer s Allowance Any other income Have you applied for Carer s Allowance but are not entitled because you are getting another Social Security benefit? Have you applied for any benefits and are waiting to hear? If, what have you applied for? Proof We need to see proof of all the income that you get. This must show your present address, the type of income and how much you receive. 11

10 About savings and investments this includes current accounts If you and your partner have a joint account, please enter the amount under the name that is first on the account. If either of you have a joint account with someone else, please give us details in section 14 Other information on page 17. Bank accounts Do you have any bank accounts? If, how many? You Your partner Please say what type of account each one is and how much money is in it Account Number Amount Account Number Amount Continue on a separate sheet if you need to. Building society accounts Do you have any building society accounts? If, how many? Please say what type of account each one is and how much money is in it Account Number Amount Account Number Amount Continue on a separate sheet if you need to. Post Office accounts Do you have any Post Office accounts? If, how many? Please say what type of account each one is and how much money is in it Account Number Amount Account Number Amount Continue on a separate sheet if you need to. Other Do you have any cash savings? If, how much? Amount Amount 12

10 About savings and investments continued You Your partner Do you have any Premium Bonds? If, please give details. How many Value How many Value Do you have any National Savings? If, please give details. Issue Number Purchase Value Issue Number Purchase Value Do you have any stocks, shares or unit trusts? If you have shares, please list the companies and the number of shares for each one. Use a separate sheet of paper if you need to. Do you or your partner own, or jointly own, any other land or properties either in the UK or abroad, including timeshare? Please give the address of any other land or properties that you or your partner own. We may write to you for more information. Have you or your partner received any compensation payments? If, please give details Proof We need to see proof of all capital, savings, investments and current accounts held by you and your partner where your capital is greater than 6,000 for working age claims and 10,000 for pensioner age claims. This must show who the money is invested with, the type of account and the amount invested. In certain circumstances we may ask you for proof of your capital where you have less than this. Remember if you are claiming Council Tax Support only you will not be entitled to support if you have more than 6,000. We cannot accept a print out from the bank or building society showing just the balance of your account. Your proof must show the last three months transactions. 13

11 About your tenancy If you are claiming Council Tax Support only go to section 14. What date did your agreement to pay rent start? How much does your landlord charge you? Weekly Fortnightly Calendar monthly 4 weekly Other What is the full name and address of your landlord/agent? Are you, your partner, or your child related to your landlord or your landlord s partner? If, please say how you are related. Please tell us about your accommodation Bedsits Bedrooms Living rooms Kitchens Bathrooms Other rooms (please state) Total Total number of rooms in the whole property Number used only by you and your family Number you share with people other than your family Is a garage included as part of your tenancy agreement? If, did you have any option about renting the garage? Does your rent include any of the following? If, please give the amount. Water rates Heating Lighting General counselling and support Emergency alarm 14

11 About your tenancy continued Does your rent include any of these meals? Breakfast Lunch Evening meal Has your rent been registered by the Rent Officer or the Rent Assessment Committee? Don t know Proof If this is your first claim we need to see: Your tenancy agreement. If you do not have one, please contact us for a Tenancy Details form. We also need to see proof of rent payments or arrears, such as receipts, rent statements, bank statements or your rent book. If you do not have proof of rent payments, please ask your landlord to confirm in writing: that you have been paying the shortfall between the Housing Benefit and the rent charged (if there is any) the amount of any arrears the amount of any credit 12 Sharing information with your landlord Sharing information with your landlord could help us deal with your claim more quickly. If you give us permission, we will be able to tell your landlord about any information we are waiting for. If we are paying Housing Benefit to your landlord on your behalf, we will also send them a decision notice. We would only give your landlord this information if they request it. However we will not give your landlord any information about your personal, household or 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. I give the council my permission to share information about the progress of my Housing Benefit claim with my landlord or their representative. Signature Date 15

13 About paying your benefit If you are a private tenant affected by Local Housing Allowance, payments will be made direct to you, unless there is a reason why you cannot receive your payment. Please tell us here why we should pay your landlord. If you are a Housing Association tenant you can ask us to pay your Housing Benefit to your landlord. Do you want us to pay your Housing Benefit to your landlord, the agent or to you? You landlord agent NB. If we make payments directly to you, we will pay you every two weeks. If we send payments to your landlord or agent we have to send them every four weeks. We cannot pay benefit in advance; payments will be sent at the end of the period they are for. Your benefit will be paid straight into the bank/building society account of your choice. We cannot pay benefit into a post office account. Please tell us about the account you want your benefit paid into. Name of bank/building society account Branch Sort Code Account number Roll number (for building society) Account name If you want your benefit paid into your landlord or agent s bank/building society account, please tell us their account details. 16

14 Other information If you would like to give us any other information which could help in working out your benefit, please tell us here. 15 Backdating Housing Benefit and Council Tax Support usually starts from the Monday after we receive your claim form. We may be able to pay benefit before the date of your claim if there is a good reason why you did not claim earlier. Please see www.lichfieldddc.gov.uk/benefits for How far can you backdate my claim? Do you want to claim backdated benefit? If, what date do you want the claim to go back to? Please explain why you did not claim earlier. 17

16 Your declaration Please read this declaration carefully before you sign and date it. I understand the following: If I give information that is incorrect or incomplete, you may take action against me. You will use the information I have given to process my claim for Housing Benefit or Council Tax Support, or both. You may check some of the information with other sources in the council, rent offices, and other councils. You may use any information I have given for this and for any other claim for Social Security benefits that I have made, or may make. You may give some information to other government organisations, if the law allows this. I know I must let the Benefits Section know promptly about any changes in my circumstances, which might affect my claim. I declare the information I have given on this form is correct and complete. Signature of person claiming Partner s signature Date If all or part of this form is filled in by someone other than the person claiming Please tell us why you are filling in this form for someone else. Name of the person who filled in the form Signature of the person Relationship to the person claiming, including appointee or power of attorney. If you are the appointee or have power of attorney, you should sign the form as if you are the claimant. Confidentiality statement The information collected on this form and the supporting evidence will be used by Lichfield District Council to work out your Housing Benefit and Council Tax Support. This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud and crime. We may also share this information with bodies responsible for auditing or administering public funds and for the purposes of conducting datamatching exercises to prevent and/or detect potential fraud and crime or as necessary to comply with any other legal obligation. We will not give information about you to anyone unless the law allows us to. Lichfield District Council is the Data Controller under the Data Protection Act. If you want to know more about the information we have about you, or the way we use your information, you can ask for this in writing. Please send your letter to the Housing Benefit Section. 18

17 Your receipt Received by Date Please keep this receipt as it contains important information regarding your claim. What happens next? Your claim and proof will be checked. If it is complete, we will process your claim and you will get a decision notice. You should check this notice carefully and contact us immediately if anything goes wrong. If your circumstances change you must tell the Benefits Section straight away. If you do not do this promptly, you will be breaking the law and the Department for Work and Pensions may take action against you. Examples of changes in circumstances are given on the claim form and also on the back of the decision notice. If you are not sure, please contact us. If you are in paid employment and your earnings vary from one pay day to the next, we use a figure that most represents what your future earnings will be, by taking an average of your pay. You need to keep the council informed of any fluctuations in your earnings. It would be helpful if you could send your pay slips into the office every three months to ensure that the earnings figure included in your assessment is correct. This will avoid an overpayment and will ensure you receive the right amount of benefit. If you are receiving Pension Credit you will usually report your changes to the Pension Service but you must still tell us about the following changes in writing: Changes to your tenancy or the amount of rent payable Changes relating to non-dependants If you are away from home for any period that is likely to be 13 weeks If your Pension Credit stops If you only receive Savings Credit you must also report Changes in household members If your capital goes above 16,000 Changes to the income of a partner not included in the pension credit claim. Discretionary Housing Payments Discretionary Housing Benefits may be awarded where the council considers that a claimant requires further financial assistance towards housing costs as a temporary measure. Awards will be made in accordance with Lichfield District Council s Discretionary Housing Payments Policy. The policy can be found at www.lichfielddc.gov.uk/dhp 19

You can find out more information about Housing and Council Tax Support by visiting our website at www.lichfielddc.gov.uk/benefits You can contact us by Email to benefits@lichfielddc.gov.uk Telephone 01543 308900 / Minicom only 01543 308078 Post to Lichfield District Council District Council House Frog Lane Lichfield Staffordshire WS13 6YX In person at the above address. The Department for Work and Pensions can be contacted at Social Security Office 15 Stafford Street Hanley Stoke on Trent ST1 1RE Telephone: 0845 608 8673 Textphone: 01782 224559 The Pension Service can be contacted on Freephone: 0800 99 1234 Textphone: 0800 169 0133 Your local Citizens Advice Bureau is at: 29 Levetts Field Lichfield Staffordshire WS13 6HY Telephone: 01543 252730 Or if you live in the Burntwood area: Wade House 7 Cannock Road Burntwood Staffordshire WS7 8JS Telephone: 0844 856 3400 Help us to prevent benefit fraud Benefit fraud is a crime. Why should you pay for it? If you have any information relating to a known or suspected benefit fraud please call: Freephone 0800 783 1030 All calls and information will be treated in confidence. 20