Housing Benefit and Council Tax Benefit claim...

Version 7: Oct 09

Housing Benefit andCouncil Tax Benefit claim form

ref:

Don’t delay - claim today!

Open: 8.30am - 5.00pmMonday, Tuesday, Wednesday and Friday

Open: 8.30am - 4.00pmThursday

Office use – date stampor issuing officer’s name, position and date

This form can be provided in large print oralternative format (e.g. electronic)

Please contact Benefit Services on 01536464000 for more details or assistance withmaking your claim

Do not delay in returning this form as benefit is normally only paid from the Monday after we receive it.Delay could lose you money. You can send evidence we require later.

For general questions or advice, telephone theBenefits Section on (01536) 464000

Phonelines Open: Monday to Friday8.40am - 5.00 pm

Benefit is usually awarded from the Monday afterwe receive this form. We require supportingevidence to pay your claim. If you do not have thesupporting evidence you should still submit thisform. To avoid a delay in paying your claim youshould however submit your evidence within 7days of returning this claim form.

Please return your completed form by post or in person to:

One Stop Shop,Grosvenor House, George Street, Corby NN17 1QB

If you do not hear from us within 14 days ofsubmitting your claim, please contact us on01536 464000

01536 464000

01536 464000

01536 464000

01536 464000

01536 464000

POLISH

RUSSIAN

PORTUGUESE

SERBO-CROAT

2

About this formThe Housing Benefit and Council Tax Benefit claim form has been specially designed to be easy to fill in. It islong, but we have to ask a lot of questions to make sure that everyone who claims gets the right amount of benefit.

You may not have to fill in all parts of the form, but you must fill in any section that is relevant to you. Everysection starts with a question to help you decide if you need to fill in that section.

Second Adult RebateIf you are the only person who is liable to pay the Council Tax on your home but you share your home with oneor more persons who are over the age of 18 and they:

Are not paying you rent for living in your home Are not your spouse or partnerHave a low gross income

You can claim Second Adult Rebate in respect of them. In order to do this you will only need to complete sections1, 3, 13 and 15 of the form and provide proof showing the gross income details of other adults who live with you.If you complete the rest of the form we will work out if you are better off getting main Council Tax Benefit orSecond Adult Rebate.

About your claim

Filling in the formPlease print clearly using black or blue ink. Do not use pencil or highlighter pen. If you make a mistake, justcross it out and put the right answer next to it. Do not use correction fluid or tape. Please initial any alterations.

Answer ‘Yes’ or ‘No’ questions by ticking ✓ the relevant boxes. If you are picking an answer from a list ofanswers, put a tick in the relevant box.

If someone else fills in the form for you, there is a special space for them to sign in Part 15.

EvidenceWe need to see evidence of some of the things you tell us about. The checklist at the end of the form will helpyou. If you are not sure if we need to see evidence of something, get in touch with us. We will tell you whatwe need to see. We cannot pay you benefit until we have seen the evidence we have asked for. Send yourevidence within 7 days of returning your form to get benefit paid promptly.

When we usually pay benefit from?If this is your first claim: We will usually pay your benefit from the Monday after we get your form.

How we collect and use informationWe will use the information you give in this form, and in any supporting evidence you send us, to process yourclaim for Housing Benefit and Council Tax Benefit.

We pass the information to other agencies or organisations such as the Department for Work and Pensions, HerMajesty’s Revenues and Customs, to detect fraud and error.

We may check information you have provided, or information about you that someone else has provided, withother information we hold. We may also get information about you from certain third parties, or give theminformation, to:

make sure the information is accurate;prevent or detect crime; andprotect public funds.

We will not give information about you to anyone else, or use information about you for other purposes, unlessrequired by law or in order to prevent fraud and error.

These third parties may include government departments, local authorities and private-sector companies suchas banks and organisations that may lend you money.

The Council is the data controller for the purposes of the Data Protection Act.If you want to know more about what information we have about you, or the way we use it, please ask us.

3

Housing Benefit and Council Tax Benefit claim formIf you are just claiming Second Adult Rebate, only fill in Parts 1, 3, 13 and 15 of this form.

Part 1 About you and your partner

No

Yes If you have a partner, you must answer allthe questions about them, as well as yourself.

Do you have a partner who normally liveswith you?A partner means a person you are marriedto or have a civil partnership with, or aperson you live with as if you were theirhusband, wife or civil partner. This alsoapplies to same sex couples. Even if yourpartner only comes home at weekends, orpart of the week, you must include them.

We need proof of your (and yourpartner’s) National Insurance Numbers

About your claim - continued

Please indicate which benefit(s) you wish to claim. If you are not sure, please tick both boxes.

Housing Benefit Council Tax Benefit / 2nd Adult Rebate

There are further questions about benefits in other parts of this form.

You Your partnerLast name (please print)

Other names

Any other last names youhave used

Title (Mr, Mrs, Ms,Other)

Address

Customers who present at The One Stop Shop a fully completed and signed application form with all necessaryevidence to support their claim, may be able to have their claim assessed within 5 working days. Alternatively,you can request a Home Visit, for help with completing the form. Please ask Customer Services for furtherinformation on these highly successful and beneficial services.

5 Working Days Fast-Track Claim Guarantee Service

Are you aged:

Do you or your partner receive:

Under 60 Over 60

Income Support Pension Credit Guarantee

Pension Savings CreditIncome Based JobSeekers Allowance

Employment SupportAllowance (Income Related)

a council tenant? an owner-occupier

a private tenant? a housing associationor social landlord tenant?

Are you (please tick one box)

Council Tax Single Person Discount

Part 1 About you and your partner - continued

You Your partner

4

/ / / /

/ / / /

Letters Numbers Letter Letters Numbers Letter

If you do not have a NationalInsurance number, or cannotfind it, tick this box

If your partner does not have aNational Insurance number, orcannot find it, tick this box.

What date did you move into this address? ie spent thenight thereDate of birth

National Insurance numberYou can find this on payslipsor letters from social securityor the tax office. We cannotdecide your claim if we do notsee evidence that this is yourNational Insurance number(see part 17).

Your daytime phone numberIn order that your claim canbe dealt with more promptly,should further information berequired.

Your e-mail addressYou do not have to tell us this,but it may help us to deal withyour claim more quickly

No

Yes When did you claim?

No

Yes When did they claim?

/ / / /

Postcode Postcode

No Date left

Yes / /

Postcode Postcode

Have you or your partnerclaimed Housing Benefit orCouncil Tax Benefit before?

Have you told the council thatpreviously paid your benefitthat you have moved?

If you have moved home in thelast 12 months, tell us your lastaddress

Were you the home owner, aprivate tenant, a council tenantor a boarder at this address?

Which council did you claim from?

What name did you claim in?

What address did you claim for?

No Date left

Yes / /

Which council did they claim from?

What name did they claim in?

What address did they claim for?


No

Yes How much?

You Your partner

No

Yes How much?

Do you or your partner getDisability Living Allowance?

Do you or your partner getAttendance Allowance?

Does anyone get CarersAllowance for looking afteryou or your partner?

Have you or your partner everclaimed Carers Allowance?Still tick ‘Yes’ if you were notpaid any Carers Allowance

Do you or your partner have avehicle from a Mobilityscheme?

Are you or your partner astudent?

No

Yes How much?

Care: £

Mobility: £

£

No

Yes How much?

Care: £

Mobility: £

£

No

Yes

No

Yes

How often?

No

Yes

Every

No

Yes

How often?

Every

No

Yes

No

Yes

No

Yes

No

Yes

5

Have you or your partnercome to live in England,Northern Ireland, Scotland,Wales, the Republic of Ireland,the Channel Islands or the Isleof Man in the last 2 years?

What is your nationality?

If your nationality is notBritish, on what date did youlast enter the UK?The UK is England, NorthernIreland, Scotland and Wales.

Are you or your partner inhospital at the moment?

No

Yes We will write to youabout this

No

Yes We will write to youabout this

/ / / /

No

Yes When did you go in?

/ / / /

No

Yes When did they go in?

When will you come out(if you know this)?

/ / / /

When will they come out(if they know this)?

6

Part 2 About children

You may be able to get more benefit if there are children in your household and they are:

● under 16;● aged 16 or 17 and registered for work or youth training; or● aged 16 - 20 and in education doing a course not higher than GCE A-level, SCE Higher level or GNVQ(advanced).

No Go to Part 3

Yes If there are more than 4 children, use a separate sheet of paper totell us all the information we ask for on this page.

If you are sending a separate sheet of paper, tick this box

We need to see proof of Child Benefit andbirth certificates for your children

Do you study full time or part time?

Full time Part time

Do they study full time or part time?

Full time Part time

Please tick if you or your partner are:

● an apprentice● on youth traning● in legal custody

We will contact you if we need any more information

You Your Partner● severely mentally impaired● registered blind● long-term sick or disabled

You Your Partner

Course

Establishment / College /University

We will need to see proof of your term dates, student loan, and details of any grant income you receive.


You Your partner

First child Second child Third child Fourth child

/ / / / / // /

Are there any children in yourhousehold?

Last name

Other names

Date of birth

What is the child’s sex?

The child’s relationship to you

The child’s relationship to yourpartner

Part 2 About children - continued

First child Second child Third child Fourth child

7

Is the child registered blind?

/ / / / / /

No

Yes

No

Yes

No

Yes

No

Yes

We need to seeevidence of this.




/ /

Usual address if different fromyours

Child Benefit number

Who gets the Child Benefit forthem?We need to see proof of this.

If over 15 years old, the expectedschool-leaving date

Does the child get DisabilityLiving Allowance?

Do you pay a registeredchildminder, nursery or after-school club any childmindingcosts for this child?

No

Yes Howmuch?

No

Yes Howmuch?

No

Yes Howmuch?

No

Yes Howmuch?

No

YesTell us thename andregistrationnumber ofthe minder.

No


No


No


How much do youpay per week?

We need to seeevidence of this







Care: £ Care: £ Care: £ Care: £

Mobility: £ Mobility: £ Mobility: £ Mobility: £

£ £ £ £

8

Part 3 About other people who live with you

Do any other adults usuallylive with you and yourpartner?By adults we mean people over16 who nobody gets ChildBenefit for.

No Go to Part 4

Yes Give details below.

Now tell us about all the people who usually live with you and your partner.

If you want to tell us about more than 3 people, use a separate sheet of paper.If you are sending a separate sheet of paper, tick this box.

Last name

Other names

Date of birth

Their relationship to you oryour partnerSome examples are aunt,brother, daughter, father,grandson, grandmother,stepdaughter, joint owner,subtenant, lodger or friend,additional partners (polygamousmarriage)

First person Second person Third person

/ / / / / /

We need to see proof of allincome

No

Yes Tell us their names and their relationship to you and your partner

How much of the rent do you pay?

every£

(for example, every week/fortnight/4 weeks/month.)

Is anyone other than you(and your partner) liable topay rent directly to yourlandlord/landlords agent?(Joint tenants)

No

Yes Tell us their names

is thepartner of

Andis the

partner of

Are any of the people whonormally live with you acouple, including a same sexcouple?

First person Second person Third person/ / / / / /

No

Yes

No

Yes

No

Yes

When did they move in?

Do they get Income Support,income-based Jobseeker’sAllowance or Income RelatedEmployment SupportAllowance?

Part 3 About other people who live with you - continued


9

No

Yes

No

Yes Tell us which.

No

Yes How much?

£ a week

No

Yes

No

Yes When are theyexpected tocome out?

/ /

No

Yes When did theygo in?

/ /

When will they come out(if you know this)?

/ /

No

Yes

No

Yes Tell us which.

No

Yes How much?

£ a week

No

Yes

No


/ /

No


/ /


/ /

No

Yes

No

Yes Tell us which.

No

Yes How much?

£ a week

No

Yes

No


/ /

No


/ /


/ /

£ a week £ a week £ a week

Are they registered blind?

Are they severely mentallyimpaired?

Are they in legal custody atthe moment?

Are they in hospital atthe moment?

Does this include moneyfor heating?

Do they pay rent or moneyfor board and lodgings to youor your partner?

Does this include moneyfor food?

No

Yes How much?

No

Yes How much?

No

Yes How much?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Do they get Disability LivingAllowance or AttendanceAllowance?

Are they a full-time student,a student nurse, a careworker, an apprentice or onyouth training?

10

No

Yes

No

Yes

No

Yes

Do they have any otherincome at all?This includes any benefits orallowances you have not toldus about on this form andinterest from savings andinvestments.

Name of firstother income

£ a week

How much is it beforedeductions?

Name of second otherincome

£ a week


Name of third otherincome

£ a week


We need to see evidenceof all other incomes

£ a week



£ a week



£ a week



£ a week



£ a week



£ a week





Fair use statementIf you do not disclose that other adults live with you or if you fail to disclose relevant changes in their circumstancesyou will be committing a criminal offence and you and / or your non-dependant will probably have to repayoverpayments arising from this. The details of your dependants and non-dependants will be filed on computer andthese records will be treated in confidence in accordance with the Data Protection Act. This information may beshared with the Department of Work and Pensions, Her Majesty’s Revenues and Customs, other Local Authorities orexternal partners of the Council or Government for the prevention and detection of fraud or recovery of debts owedto the Council. We will do this only where allowed or required to by law. In order to accurately assess the contributionyour non dependant (s) will be required to make towards the rent or Council Tax we will be required to verify theirincome details. If you have told us that other people in your household are in receipt of a Social Security Benefit, wecan do this by contacting the Department of Work and Pensions, we may do this electronically.

No

Yes Tell us theirearnings beforeany deductions

£

We need to seeevidence of theirearnings.

No


£


No


£


Do they normally work for16 hours or more a week

Part 3 About other people who live with you - continued


Part 4 About rent

Do you rent your home?Tick ‘Yes’ if you would pay rentbut you already get HousingBenefit.

When did you start rentingyour home?If you have not moved in yet,tell us when you expect tomove in. When you actuallymove in, tell us at that time

Do you rent your home fromthe Council?Tick ‘Yes’ if you would pay rentbut get Housing Benefit.

What is your landlord’s nameand address?By landlord we mean theperson or organisation whoowns the property you live in.

If your landlord has an agent,tell us their full name andaddress.By agent we mean the personor organisation you actuallypay your rent to.

Are you, your partner, or anyof your or your partner’schildren related to yourlandlord or agent, or to yourlandlord’s partner or theagent’s partner?Related includes relatedthrough marriage, even if themarriage has ended. Someexamples are ex-wife, ex-husband, aunt, brother,daughter, father, grandson,grandmother, son-in-law orstepdaughter.

Are you or your partner adirector, shareholder oremployee of your landlord?

Have you or your partnerowned your current home inthe last 5 years?

May we discuss the progress ofyour claim with your landlord?We will not disclose personal/income information

No Go to Part 6

Yes Answer the next two questions

/ /

No Answer all the questions below

Yes Go to Part 6.

Postcode

Postcode

No

Yes What is the relationship?

is my landlord’sor agent’s

No

Yes

No

Yes

No

Yes

I authorise the Council to discuss my benefitclaim with my landlord

Signed DatePlease sign here

We need proof of the rent you pay

11

Part 4 About rent - continued

What sort of tenancy do youhave?For example, assuredshorthold, assured, secure/registered tenancy, tied.You can check this on yourtenancy agreement or rentbook if you have one.

How long is the tenancy for?

Please tick to show if theproperty is let as:

furnished

partly furnished

minimally furnished

unfurnished

How much is the rent for yourhome?

Has your rent changed in thelast 12 months?

When is the next rent increasedue?

Has your rent been registeredas a fair rent by a rent officer?

Are there any weeks when youdo not have to pay rent?

Are you behind with yourrent?

/ / to / /

That is, completely furnished

That is, some furniture, but not all

That is, just two or three items

That is, no furniture at all

every£

(for example, every week/fortnight/4 weeks/month.)

No

Yes Send us evidence of the date it changed, and how much it changed.

/ /

No

Yes Please send us the notice of registration (R05).

No

Yes How many in a year?

No

Yes By how many weeks?

12


No

Yes How much each week? £

Which meals are included? All Breakfast EveningNo


No


No


No


No


No


No


No


No


Do you have to rent the garage aspart of your tenancy agreement?

No

Yes

No


No


What for?

Does your rent include money for the following?

Meals

Water authority charges

Heating

Lighting

Hot water

Fuel for cooking

Laundry done for you

Cleaning rooms or windows

Gardening

Garage or parking space

Personal care and support

Do you pay any servicecharges separate from yourrent?For example, for cleaning or lighting inshared areas, an alarm system, awarden, general counselling or support,meals or lift maintenance.

Who has to pay the Council Tax bill for your home?Tick the box that applies.

You or your partner

Your landlord Someone else

Tell us who it is What is the CouncilTax referencenumber?

13


Are you living away fromhome at the moment?

No Yes Tell us why you are not living at home.

/ /When did you last live at home?

/ /When do you expect to go back home?

Tell us the address where you are living at the moment.

Postcode

If your home has been sublet, tell us who lives there now.

We must see evidence of your rent and tenancy before we can decide how much benefit you can get.Read the checklist at Part 17 to see what you can use as evidence.

Part 5 About where you live

What sort of building do you live in? Tick one box only.

Detached house

Semi-detached house

Terraced house

Maisonette

Bungalow

Other (please say what)

Flat in a house

Flat in a block

Flat over a shop

Bedsit or rooms

Hostel

Caravan, mobile home or houseboat

Board and lodgings

Hotel

Residential nursing home

Residential care home

Does your home have centralheating?

Does your home have a garden

Has your home been built oradapted for people withdisabilities

Which floors do you live on?

How many floors are there inthe building?

Do you and your householdoccupy only part of thebuilding you have ticked?(e.g. if you rent a room andhave shared access to otherfacilities tick yes).

No Yes

No Yes

No Yes

All Basement Ground 1st 2nd 3rd

No

Yes Looking at the front, where in the building do you live?

At the front In the middle At the back

Left Hand Side Centre Right Hand Side

14

Part 5 About where you live - continued

How many rooms are there inthe building

Living rooms

Bedsitting rooms

Bedrooms

Bathrooms or shower rooms

Toilets

Kitchens

Other rooms

Do you use your home forbusiness?

Do you have a main homesomewhere else?If your main home issomewhere else in the UK orabroad, tick ‘Yes’, even if youdo not pay rent for it.

In the wholebuilding

Just for you andyour household?

That you share withother people?

No Yes

No Yes What is the address?

Postcode

How much do you pay for this home? £

Part 6 About Income Support, income-based Jobseeker’sAllowance, Pension Credit Guarantee and EmploymentSupport allowance

Are you or your partnergetting, or waiting to hearabout a claim for, IncomeSupport, income-basedJobseeker’s Allowance,Employment SupportAllowance (Income Related)or Pension Credit?

No Go to Part 7

Yes Answer both the questions in this part, then go to Part 10.

No

Yes When did you startgetting it?

You Your partnerNo

Yes When did they startgetting it?

/ / / /

When did you claim? When did they claim?

/ / / /

15

We need to see proof

Are you or your partneractually getting IncomeSupport, income-basedJobseeker’s Allowance,Employment SupportAllowance (Income Related)or Pension Credit at themoment?

If you or your partner are stillwaiting to hear about a claimfor Income Support, income-based Jobseeker’s Allowance,Employment SupportAllowance (Income Related)or Pension Credit.

Part 7 About being self-employed

Are you or your partner self-employed?This includes being a directoror company secretary of anybusiness.

What kind of work do you do?

When did the business start?

What is the business address?

Are there any other partners inthe business?

How many hours a week doyou usually work?

Do you get a Business Start-upAllowance?

Do you pay into a privatepension scheme?

No Go to Part 8

Yes Answer the questions on this page.You must send us your trading accounts for the last financial year.If you have only recently set up the business and do not have a fullyear’s accounts, we will need to see some evidence of your incomeand expenditure relating to your self-employment.

You Your partner

Postcode

/ /

No

Yes Tell us their name andaddress.

Postcode

No

Yes How much?

£

How often?

Every

No

Yes How much?

£

How often?

Every

Postcode

/ /

No

Yes Tell us their name andaddress.

Postcode

No

Yes How much?

£

How often?

Every

No

Yes How much?

£

How often?

Every

We must see evidence of your earnings before we can decide how much benefit you can get.Read the checklist at Part 17 to see what you can use as evidence.

16

Do you or your partner workfor an employer?

Do you work for more thanone employer?

What kind of work do youdo?

What is your employer’sname and address?

When did you start this job?

What is your payroll,employee or staff number?

Are you employed for a fixedperiod?

How often do you get paid?

How much do you get paidbefore deductions?(gross pay)

How are you paid?For example, in cash, chequeor straight into a bank orbuilding society account.

When was your last pay rise?

When will your next pay risebe?


Give details of any regularovertime, bonuses orcommission.

Are you getting StatutorySick Pay (SSP) or StatutoryMaternity Pay (SMP) fromyour employer at themoment?

When did it start?

Part 8 About working for an employer

You Your partner

/ /

/ /

Every

No Go to Part 9

Yes Answer the questions in this part.

No

Yes Tell us about all the employers on a separate sheet of paper andsend it with this formIf you are sending a separate sheet of paper, tick this box.

Postcode

No

Yes When will you finish?

£

/ /

/ /

No

Yes

/ /

/ /

/ /

Every

Postcode

No

Yes When will they finish?

£

/ /

/ /

No

Yes

/ /

17

We need to see evidence ofall earnings

Part 8 About working for an employer - continued

Are you getting any other sickpay or maternity pay fromyour employer at the moment?

When did it start?

Do you pay into a private orcompany pension scheme?

No

Yes

/ /

No

Yes

/ /

No

Yes How much?

No

Yes How much?

£

How often?

Every

£

How often?

Every

Normally we must see 5 weekly or 2 monthly consecutive pay slips before we can decide how much benefityou can get. If you have just started work we can accept a letter from your employer confirming hoursworked and salary. We may then ask you to provide further evidence once you have it. Read the checklist atPart 17 to see what you can use as evidence. If you get tips or bonuses, tell us about these in Part 14.

Part 9 About any other work

Do you or your partner do anyother work at all?This could be voluntary workor any other work, even if it isnot paid work.

What other work do you do?

What is the name and addressof the person you do this workfor?

When did you start this work?


Do you get paid?If you only get expenses or tips,still tick ‘Yes’ and give details.

You Your partner

No Go to Part 10

Yes Answer the questions on this page

Postcode

/ /

No

Yes How much do you getbefore any deductions?

£

How often?

Every

We must see evidence of any earnings/expenses or tips before we can decide how much benefit you can get.Read the checklist at Part 17 to see what you can use as evidence.

Postcode

/ /

No

Yes How much do they getbefore any deductions?

£

How often?

Every

18

If working as a retained firefighter,auxillary coastguard , lifeboat crew or

territorial or reserve forces pleaseprovide evidence

Part 10 About benefits, tax credits and state pensions

Are you or your partner getting any benefits or waiting to hear about benefits youhave claimed?Read the list of benefits below and tell us about any that you or your partner aregetting now or have claimed. Please enter a zero in any boxes that do not apply toyou or your partner.

You Your partnerWaiting to

hear✓

How muchdo you get?

How oftenis it paid?

How muchdo they get?


Contribution-based Job Seeker’sAllowance

Child Tax Credit

Working Tax Credit

Employment Training Allowance

Child Benefit

Short-term Incapacity Benefit

Long-term Incapacity Benefit

Employment Support Allowance

Attendance Allowance

Disability Living Allowance:Mobility ComponentCare Component

Carer’s Allowance

Severe Disablement Allowance

Maternity Allowance

Fostering Allowance

Any other benefit, pension ormoney from the government

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

19

We need tosee proof

State Retirement Pension

Pension Credit Guarantee

Widow’s Allowance orBereavement AllowanceWidowed Parent’s Allowanceor Widow’s Pension

War Widow’s or WarDependant’s Pension

War Disablement Pension

Exceptionally SevereDisablement Allowance

Industrial Injury/DisablementPension

Waiting tohear

✓

££Pension Savings Credit

£ £

Part 11 About other money or pensions coming inDo you or your partner have any money coming in (or expect to havesome money coming in) that you have not already told us about on thisform?

No Go to Part 12

Yes Answer the questions onthis page. Please put azero in any boxes thatdo not apply to youor your partner.

You Your partnerYes✓

How muchdo you get?


Yes✓

How muchdo they get?


This includes work based pensions; maintenance or child support for you,your partner or any of the children you have told us about on this form;money from a trust fund; training allowances; a student grant or loan; andany cash payments. Also tell us about any money you get from peopleliving in your house as boarders, lodgers or subtenants. You do not needto tell us about payments from the Independent Living Fund, The EileenTrust or the MacFarlane Trust or any charitable or voluntary payments.

Other income and pensions

Private Pension 1 paid by

Private Pension 2 paid by

Date next increased / /

Does anyone owe money to you, your partner, or any children you are claiming for?

What for?

How much?

Who is it owed to?

What for?

How much?

Date next increased / /

Date next increased / / Date next increased / /

Other money 1 Other money 2 Other money 3

No

Yes

No

Yes Tell us about it below Tell us about it below

Are you expecting to get any money in the next 12 months?For example, a redundancy payment or a payment instead of notice or holiday.

£ £

£ £

No

Yes Tell us about it below

No

Yes Tell us about it belowTell us about it belowTell us about it below

£ £ £

£ £ £

We must see evidence of any money or pension coming in before we can decide how much benefit you canget. Read the checklist at Part 17 to see what you can use as evidence.

£

£

£

£

£

£

£

£

£

£

£

£

Youth Training Schemepayment or Training CreditsMaintenance payments youreceive – including CSAStudent grant or loan

Payments from boardersWeekly amount from letting orsub-letting part of a property

Any other income

(please give name)

No

Yes

No

Yes

20

Part 12 About capital, savings and investments

Do you or your partner haveany bank, building society,post office or any otheraccounts or any capital,savings, investments orproperty in the UK or abroad?

No Go to Part 13

Yes Answer all the questions in this part. We must see evidence of allbank accounts, capital, savings and investments. Read thechecklist at Part 17 to see what you can use as evidence. We willneed statements or pass books covering the last 2 months at least.

All bank or post office accounts(including current accounts)

Account number/name/other details Your balance Partner’s balance

£ £

£ £

£ £

Building society accounts

Stocks, shares, unit trustsList the names of investmentsand number of shares held

National Savings CertificatesList the issue, purchase dateand number of units

Other investments,redundancy payments,premium bonds, tessa’s,ISA’s, SAYE, cash etc(Please also use this space ifyou need more room for anyof the above savings)

£ £

£ £

£ £

£ £

£ £

£ £

£ £

£ £

£ £

£ £

Please supply up-to-date statements or pass books for all accounts held, even if overdrawn, covering the last 2months

Please answer these questions for yourself and your partner. Please include empty and overdrawnaccounts, whether in single name or jointly held with anyone else.

21

We need to see proof if you have any of the following capital assets including current savings, funeral,Christmas savings and Credit Union accounts, stocks and shares and details of any property you own.

This includes cash, current accounts, and savings accounts with a bank or building society, Tessas, PEPs, ISAsor any other savings scheme whether tax free, offshore or otherwise, post office accounts, basic bank accounts,premium bonds, National Savings Certificates, stocks, shares and property.

Part 12 About capital, savings and investments - continued

Do you, your partner, or anychildren you are claiming forown or partly own anyproperty, land or timeshare,other than the home you livein, either in the UK orabroad?Tick ‘Yes’ even if you have amortgage or loan for theproperty, land or timeshare.This includes jointly ownedproperties.

No

Yes What is the address?

Postcode

Part 13 BackdatingWe can usually award benefit from the Monday after we receive your claim. Sometimes we can pay benefits from anearlier date if you have good reason for not claiming earlier. If you want us to consider paying your benefit from anearlier date, you can send us a letter with your reasons or tick here and we will send you a backdating form. I wishto apply for a backdate.

How much is it worth?

If you have a mortgage or loanfor this, how much is left torepay?

Have you or your partnerreceived a Far Eastern Prisonerof War payment and/or

You Your partner

a compensation paymentmade to victims of atrocitiesthat happened during theSecond World War?

No

Yes

No

Yes

What payment did youreceive?Far Eastern Prisoner of WarCompensation payment.

Compensation payment madeto victims of atrocities thathappened during the SecondWorld War.

£ £

££

Have you, your partner or anychildren you are claiming forreceived a payment from thevCJD (Creutzfeldt-JakobDisease) Trust?

No

Yes

We need to know this to make sure we do not count it as part of your savings

We will write to you about it.

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Part 15 Declaration

23

Changes you must tell us aboutTell us straightaway if:● any of your children leaves school or leaves home;● anyone moves in or out of your home (including lodgers and subtenants);● your income or the income of anyone living with you, including benefits, changes;● your capital, savings or investments change;● you or anyone living with you becomes a student, goes on a Youth Training Scheme, goes into hospital or a

nursing home, goes into prison, or gets, changes or leaves a job;● your rent changes;● you move house or move room within a house;● you or your partner are going to be away from home for more than a month;● you receive any decision from the Home Office; or● anything you have told us about changes.

You must tell us about these changes in writing – if you phone we will need you to confirm any changes inwriting.

If you don’t tell us about these changes, you may lose money you are entitled to or you may get too much benefit.You must make sure that you tell us about these changes. Don’t rely on someone else to pass on the message. Itis an offence not to tell us about any change of circumstances that affects your benefit. We may take court actionagainst you. If we pay you too much benefit, you will probably have to pay it back.

Even if someone else has filled in this form for you, you MUST sign this declaration if you can. If you have apartner, please ask them to sign page 24 to confirm that all the details about them are correct.

Please read this declaration carefully before you sign and date it.

Part 14 Anything else you need to tell usUse the box below to tell us anything else you think we should know about.Use a separate sheet of paper and attach it to this form if you need to.If you are sending separate sheets of paper with this form, tell us how many.

24

If this form has been filled in by someone other than the person claiming:Please tell us why you are filling in this form for the person claiming.

As far as possible, I have confirmed with the person claiming that the answers I have written on this form arecorrect.

Name of the person whofilled in the form

Signature of the person

Relationship to the personclaiming

Date / /

Part 15 Declaration - continued

I understand that it is a criminal offence to withhold or provide false information in order to obtain, retain or increasebenefit entitlement. I understand that the Council will take action and seek penalties from those committing orcolluding with fraud.

The Council will use the information I have provided to decide my claim for Housing and or Council Tax Benefits.The Council may, subject to my consent, use the information to assess any discount or grant for Council services. TheCouncil may check the information provided with other sources as allowed by law.

The Council may use any information I have provided in connection with this and any other claim for SocialSecurity benefits that I have made or may make to decide and verify entitlement. This includes any DiscretionaryHousing Payment. Where I have stated that I or other members of my household are in receipt of a Social Securitybenefit the Council may verify that information directly. My records and those of the people on this claim form willbe recorded and processed on a computer system in accordance with the Data Protection Act and will be treatedwith strict confidentiality. I understand that these records may be shared with the Department of Work and Pensions,Her Majesty’s Revenues and Customs, other Local Authorities or external partners of the Council or Government toverify entitlement or continuing entitlement to benefit and for the prevention and detection of fraud or recovery ofdebts owed to the Council.

I know I must let the Housing Benefit Department know about any change in my circumstances or the circumstancesof anyone living with me, which might affect my claim. Please note that if you report a change of circumstance to theDWP you will also need to inform the council of this change.

I declare the information I have given on this form is correct and complete

Signature of person claiming

Date

Partner’s signature

Date

/ /

/ /

25

Send direct to Landlord (Housing Association tenants only) YES NO

IMPORTANT – We can only arrange to pay into:an account in your name ora joint account with your partner named in this application

If you have not got a current or basic account and have previously been unable to open one, please ask for ourleaflet giving details of the new Basic Bank Accounts that you can open. A Basic Bank Account will give you acash machine card, which in most cases you can use to draw cash at post offices, but no debit card, chequebook or overdraft.

If you are unable to open any sort of bank account, or are unable to manage a bank account, we may be able topay your Housing Benefit by cheque. Please explain below why you cannot open a bank account or receivepayment direct to an account:

Name and address of Bank/Building Society

Branch Account Name

Whose name is the account in?

Account number Sort code

Part 16 Payment of Housing Benefit or Local Housing Allowance

Those tenants affected by Local Housing Allowance will normally be paid direct to themselves who will then paytheir landlord. However, we will consider making direct payments to Landlords for tenants who are unable tomanage their own affairs; or who are not capable of taking responsibility for the payment of their own rent; or it theyare 8 weeks or more in arrears of their rent. Please contact us if you would like further information on this or wouldlike to apply for direct payments to your Landlord.

If you are not a council tenant, or a Housing Association tenant your Housing Benefit or Local HousingAllowance will normally be paid to you straight into a nominated bank account. Please complete the detailsbelow. You can detach this page and send it back as soon as possible (ideally within 7 days).- DO NOT DELAY YOUR CLAIM.

Address you are applying forHousing Benefit or LocalHousing Allowance at:

26

Part 17 Checklist

We must see original documents, not copies. If you bring them to our reception, we will take thedetails we need and give you the document back straightaway.

If you do not provide all the evidence we need, we might not be able to pay you any benefit. Weneed the same evidence for your partner, if you have one, and for any other adults living in yourhome.

If you cannot send the evidence we need at the moment, send the form back to us now and sendthe evidence later. We can start to process your claim, but we will not be able to pay you anybenefit until we have all the evidence. Please tell us now in Part 14 if you cannot supply theevidence immediately.

Evidence of identitySuch as birth certificate, marriage certificate, passport, National Insurance number card, medicalcard, driving licence, UK residence permit, EU Identity card or recent gas or electricity bill. Wemay need to see several of these documents for each person.

Evidence of National Insurance NumberSuch as National Insurance number card, payslips or letters from social security or the tax office.

Evidence of capital, savings and investmentsSuch as all your bank, building society or post office books, full bank statements, or certificates forpremium bonds, National Savings Certificates, ISAs, Tessas, stocks, shares and unit trusts. Weneed to see evidence of any interest or dividends you get on Investments and savings. Theevidence you send must show details for at least the last 2 months.

Evidence of earningsThis means your last 5 payslips if you are paid every week, your last 3 payslips if you are paidevery 2 weeks, or your last 2 payslips if you are paid every month. We will give you a form foryour employers to fill in if you do not have these payslips. If you or your partner are self-employed, we need to see accounts for the last financial year or, if you have been trading for lessthan 6 months, a summary of your trading records so far. We can supply a form.If you have just started work we can accept a letter from your employer confirming hours workedand salary.

Evidence of other incomeSuch as pension slips from a former employer or a letter from the court showing how muchmaintenance you are getting. We need to see evidence of any money people pay you for boardand lodgings.

Evidence of benefits, allowances, tax credits or pensionsSuch as current award notices or letter from social security confirming how much you get. If youdo not have evidence, let us know straight away. Please do not send order books through the post.

Evidence of a private rent and tenancySuch as rent book, rent receipts, a tenancy agreement or a letter from your landlord, or we cansupply a form.

Evidence of other money paid outSuch as letters about student grants or maintenance, agreements or receipts from registered childcarers.

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Part 18Equal Opportunities

Corby Borough Council is committed to continuous improvement of our services to customers. To help us betterunderstand the needs of our customers please complete this form and return it with your claim form. This partwill be detached from your claim and any replies you chose to give will be entirely confidential and will notaffect the outcome of your claim in any way.

Please fill in the questionnaire below by putting a tick ( ✓✓✓✓✓ ) in the box in each category that best describes you.

Your Age Range:

19 and under 40 – 44

20 - 24 45 – 49

25 - 29 50 – 54

30 - 34 55 – 59

35 - 39 Over 60

Your Gender: Male Female

Your Ethnic Origin:

Asian or Asian British

Indian

Bangladeshi

Pakistani

Any other Asian background

Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Black or Black British

Caribbean

African

Any other black background

White British

English

Scottish

Welsh

Irish

Any other White background

If you class your ethnic origin as other please state

Chinese or other ethnic group

Chinese

Any other

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Part 18Equal Opportunities - continued

Do you class yourself as disabled?

“A Disabled person is defined in the Disability Discrimination Act as someone with a physical ormental ompairment that has a substantial and long-term impact on their ability to carry out day-to-dayactivities”.

This excludes situations where sight can be corrected by glasses or contact lenses.

Having read this do you consider yourself to be covered by the definition?

If you would like to, please indicate (using the boxes below) the nature of your disability (tick as many asare applicable)

Mobility (physical disability)

Mental health difficulty

Blind/partially sighted

Progressive disability/chronic illness (e.g. MS, Cancer)

Deaf/hearing loss

Learning disability

Other - please specify below

Sexual Orientation:

Your Religion:

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

None

Other - please state

Bisexual

Gay

Heterosexual

Lesbian

Do you require correspondence and communication in an alternative format? Yes No

British Sign Language

Audio

Braille

Correspondence in an alternative language

Verbal communication in an alternative language

Please state language

Other - please state

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