APPLICATION FOR COUNCIL TAX DISCOUNT FOR SEVERE MENTAL IMPAIRMENT

							       Return all forms to: FREEPOST (MID 24367) Local Taxation, Moorlands House, Stockwell Street, Leek, Staffordshire
       Moorlands, ST13 6BR.

     APPLICATION FOR COUNCIL TAX DISCOUNT FOR SEVERE MENTAL IMPAIRMENT

Note for Person assisting Applicants: You should complete this form and send it along with
any evidence of entitlement to benefits, to the applicant's doctor. In most cases, the doctor will
be familiar with the applicant's medical history, and may not need to see him/her before
completing the certificate.

FULL NAME OF APPLICANT:

ACCOUNT REFERENCE No:

ADDRESS:


 I declare that the person named above is entitled to one or more of the benefits listed below and
I enclose evidence of such entitlement.
 DOCTOR'S NAME:
(This will normally be the
applicant's G.P.)
 ADDRESS OF
SURGERY/HOSPITAL:

Request to Doctor: Please complete the certificate stating whether the person named is
severely mentally impaired. Please send this application form, the enclosed documents which
relate to the applicant's entitlement to benefits, and the certificate to the Local Authority.


SIGNATURE OF PERSON
ACTING ON APPLICANT'S
BEHALF:
FULL NAME:

RELATIONSHIP TO
APPLICANT:
ADDRESS:




DATE:
               QUALIFYING BENEFITS FOR COUNCIL TAX DISCOUNT FOR
                      SEVERELY MENTALLY IMPAIRED PEOPLE

To qualify for Council Tax discount, a person who is severely mentally impaired must be
entitled to one of the following benefits, or, in the case of a benefit which ceases to be
payable on reaching pensionable age, have been in receipt of that benefit until it ceased
for that reason.

         (a)   Incapacity Benefit under Section 30A of the Social Security Contributions
               and Benefits Act, 1992 as amended from 13th April, 1995;

         (b)   an attendance allowance under Section 64 of that Act;

         (c)   a severe disablement allowance under Section 68 of that Act;

         (d)   the highest or middle rate care component of the disability living allowance
               (DLA);

         (e)   an increase in the rate of his disablement pension under Section 104 of that
               Act (increase where constant attendance needed);

         (f)   a disability working allowance under Section 129 of that Act for which the
               qualifying benefit is one falling within subsection (2)(a)(i) or (ii) of that
               section, or is a corresponding Northern Ireland benefit;

         (g)   an unemployability supplement under part 1 of Schedule 7 to that Act;

         (h)   a constant attendance allowance under:

               (i)    article 14 of the Personal Injuries (Civilians) Scheme 1983; or

               (ii)   article 18(1) of the Naval, Military and Air Forces etc. (Disablement
                      and Death) Service Pension Order, 1983 (including that provision as
                      applied, whether with or without modifications, by any other
                      instrument);

         (i)   income support where the applicable amount includes a disability premium;

         (j)   disability working allowance where the person was previously in receipt of
               income support with a disability premium.

                            DETAILS OF QUALIFYING BENEFITS
 1. Which benefit is the applicant entitled to:

 2. Please state the Allowance Number:

 3. Please state the date on which the benefit became payable:

 Signed:

 Date:
                APPLICATION FOR COUNCIL TAX DISCOUNT FOR
                          SEVERE MENTAL IMPAIRMENT


CERTFICATE

This certificate is for use in deciding whether the person named is severely mentally
impaired for Council Tax purposes.

Full Name of Applicant:…………………………………………………………………

For the purposes of the Local Government Finance Act, 1992, a person is severely
mentally impaired if he / she has a severe impairment of intelligence and social
functioning (however caused) which appears to be permanent.

In my opinion, the person named above is severely mentally impaired and has been
so from (date)................................................................................................

Doctor’s Signature: ……………………………………………………............................

Doctor’s Full Name:...............................................................................................
(IN BLOCK CAPITALS)

Surgery / Hospital:………………………………………………......…………….....…….
Address:

Doctor’s Status: (GP etc): ............................………...…………………….....……........

Date:              ………………………………………………………...………………………

To the Doctor:               Please return the application, the certificate and the evidence
                             of applicant’s entitlement to benefits (which has been sent to
                             you by the applicant or person assisting them), to the Local
                             Authority.
SEVERELY MENTALLY IMPAIRED GUIDANCE NOTES                           (TO BE RETAINED BY APPLICANT)

The full Council Tax bill assumes that there are 2 adults residing in a dwelling. However, for Council Tax
purposes, certain people will not be counted when looking at the number of adults.

The effect of disregarding certain adults may be to reduce the Council Tax bill by 25% or 50%.

 EXAMPLE: 4 adults residing in a property:

 (i) One person in disregarded category:                       100% charge as there are still more than 2 adults to be
                                                               counted.
 (ii) Two persons in disregarded category:                     100% charge as there are still 2 adults to be counted.
 (iii) Three persons in disregarded category:                  75% charge as only one adult is to be counted.
 (iv) Four persons in disregarded category:                    50% charge as there are no adults to be counted.

Below are answers to some questions about who should be disregarded, under this category, for the
purpose of assessing Council Tax discount.

Q       How is ‘severely mentally impaired’ defined?

A.      For the purposes of the Local Government Finance Act, 1992 a person is severely mentally impaired
        if he / she has a severe impairment of intelligence and social functioning (however caused) which
        appears to be permanent.

Q       What does this mean in practical terms?

A.      A person will be disregarded on the grounds of being severely mentally impaired if:

        (i)     He / she is entitled to one of the following benefits:

                   Severe Disablement Allowance or Invalidity Benefit
                   Unemployability Supplement or Unemployability Allowance
                   Attendance Allowance or Constant Attendance Allowance
                   The care component of a Disability Living Allowance at higher or middle rate
                   Disability Working Allowance

                AND

        (ii)    He / she is confirmed as being severely mentally impaired by a registered medical
                practitioner.

Q.      What should I do if the person(s) I am applying for are not in receipt of one of the above
        benefits but I think they may be entitled to?

A.      If you would like more information about any benefit contact the Department of Work & Pensions
        (DWP) Tel: 01782 216600 BEFORE applying for discount.

Q.      How do I apply?

A.      Complete page 1 of this form and send it along with any evidence of entitlement to benefits, to the
        applicant’s doctor.

Q.      For how long will the discount be allowed?

A.      For as long as there are less than two adults in the property who are not disregarded. If there is any
        change in circumstances then you must notify the address shown overleaf. Failure to do so may
        result in a penalty being imposed.

Data Protection Act, 1984

The information you provide on this form will be used to determine if you are eligible for a discount from your
Council Tax, and may be recorded on a computer. Although you are not obliged to give this information, the
Council will be unable to assess your eligibility for a discount unless you do so.