A claim for Housing Benefit Council Tax Benefit Borough by pluggtwo

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									AclaimforHousingBenefit&CouncilTaxBenefit                                                                                             page 
Borough of Poole,POBox722,CivicCentre,Poole,DorsetBH152YE
Tel:(01202) 633114Minicom:(01202)743636Fax:(01202) 633150FraudFreephoneConfidentialHotline:0800 096 3596
Email:financialservices@poole.gov.ukWebsite:www.boroughofpoole.com
Offices open: Monday to Thursday 8.30am - 5.15pm, Friday 8.30am - 4.45pm.

 Name                                                   Information to claimants:                       Wewillonlytalktoyouoryourpartnerabout
 Address                                                    D
                                                        •  onotdelayreturningthisformwhile      yourclaim.Ifyouwantustotalktosomeone
                                                            youarewaitingfordocumentswe           else,likeafriend,relativeoryourlandlord,
                                                            needasproof.Ifnecessary,youcan      pleasegivetheirdetailshere.
                                                            providetheproofwithinonemonth         Name:
                                                            ofsendinginyourform.
                                                        •   Pleasefillinthisforminblackink,
                                                            andensurethatallproofprovidedto      Address:
                                                            supportthisapplicationareoriginal
                                                            documents.
Your daytime phone number and e-mail address
Youdonothavetogivethesebuttheymayhelpus     •   Ifyouneedadviceonhowtofillin
todealwithyourclaimmorequickly.                       thisform,pleasecontacttheBenefits
                                                            Officeattheaboveaddress.                                       Postcode
Daytime phone number                                    •   Youcanbringyourfilledinformand
                                                            prooftotheCouncil.Wewillcheck       Relationship to you:
                                                            andphotocopyyourdocumentsbefore
                                                            returningthemtoyou.
E-mail address
                                                        •   Wemayneedtovisityouathometo        Phone number:
                                                            confirmsomeofthedetailsonthis
                                                            form.
 I want to Claim:                                       •   Youmustanswerallthequestionson
                                         No                 thisform.Ifyoudonotanswerallthe    Office use:
 HousingBenefit                         Yes                questions,wewillreturntheformto
                                                                                                         Reference number:
                                                            youandthismaydelayyourbenefit.
                                         No
 CouncilTaxBenefit                                    •   Youcandoanestimateofentitlement
                                         Yes                                                             Date sent:
                                                            onlineat:www.dorsetforyou.com/
                                                            benefitscalculator
 SecondAdultRebate(only)              No                                                              Date received:
                                         Yes            Please send this form to us quickly
                                                        or you may lose benefit.
LABF8
 Part               About you and your partner                                                                                              page 


If you are just claiming Second Adult Rebate, only fill in Part 1, Part 3 and Part 17 of this form.


Do you have a partner who normally                    No      Youmustanswerthequestionsbelow
lives with you?
                                                      Yes     fyouhaveapartner,youmustanswerallthe
                                                              I
Apartnermeansapersonyouaremarriedto
                                                              questionsaboutthem,aswellasyourself.
orhaveacivilpartnershipwith,orapersonyou
livewithasifyouweretheirhusband,wifeor
civilpartner
(A civil partnership is a formal arrangement
that gives same sex partners the same legal
status as a married couple).                            You                                                 Your partner

Surname or family name

Other names

Any other names you
have used

Title (Mr, Mrs, Ms, other)

Address
Do not tell us your partner’s address if it is the
same as yours.


                                                                                Postcode                                          Postcode

Date of birth                                                  //                                      //


When did you move to this address?                             //                                      //
If you have not moved in yet, tell us when you
expect to move in, then tell us when you have
actually moved in.
Notes for filling in the form
Please tear off these notes and retain them for reference. You should use the 'Change of Circumstances Form' overleaf
if your circumstances change in the future from the details you have included on this form.

Filling in the form                                                                  How your Benefits Office collects and uses information
Ifyoumakeamistake,justcrossitoutandputtherightanswernexttoit.       Wewillusetheinformationyougiveinthisform,andinanysupporting
Donotusecorrectionfluidortape.                                                 evidenceyousend,toprocessyourclaimforHousingBenefitandCouncil
AnswerNoorYesquestionsbyputtingatickintherelevantbox.Ifyou            TaxBenefit.Itmayalsobeusedfortheaccountingandrecoveryof
arepickingananswerfromalistofanswers,ticktheappropriatebox.             CouncilTax.
Donotputacrossinanyboxes.Ifyouansweraquestionwithacross,we          Thisauthorityisunderadutytoprotectthepublicfundsitadministers,
mayhavetosendtheformback,andthiswilldelaytheclaim.                       andtothisendmayusetheinformationyouhaveprovidedonthis
Ifsomeoneelsefillsintheformforyou,theytoomustsigntheform.            formforthepreventionanddetectionoffraud.Itmayalsosharethis
Thereisaspecialspaceforthemtosign.                                          informationwithotherbodiesresponsibleforauditingoradministration
                                                                                     publicfundsforthesepurposes.
Proof
                                                                                     Theseotherbodiesincludegovernmentdepartments,liketheDepartment
Weneedtoseeproofofsomeofthethingsyouwriteaboutontheform.             ofWorkandPensions;otherlocalauthoritiesandprivate-sector
ThereisachecklistinPart 16oftheformtohelpyou.Ifyouarenotsure        organisationssuchasbanksandorganisationsthatmaylendyoumoney.
ifweneedtoseeproofofsomething,getintouchwithusandwewill
tellyouwhatweneedtosee.Wecannotpayyoubenefituntilwehave               Wewillnotgiveinformationaboutyoutoanyoneelse,oruse
seentheproofweneed.                                                              informationaboutyouforotherpurposes,unlessthelawallowsthis.
                                                                                     YourlocalcouncilisthedatacontrollerforthepurposesoftheData
If you need help to fill in the form                                                 ProtectionAct.
Ifyouneedanyhelp,contacttheCouncil'sBenefitsServicebytelephone
                                                                                     If you want to know more about what information we have about you,
orvisitusatthecouncil'soffices.Ifyouhavedifficultsfillingintheform
                                                                                     or the way we use that information, please ask us.
andyoucannotcomeintotheoffices,wemaybeabletoarrangefor
someonetovisityouinyourhome.Pleasetelephoneustoarrangeavisit.
OryoucangetintouchwithanorganisationliketheCitizensAdvice
Bureau.

What to do next
Whenyouhavefilledintheformsignitandsendittouswiththe
proofweneedtosee,youcanbringtheformandprooftoouroffices.
Donotsendvaluableitemssuchasbenefitorderbooks,bankbooksor
passportsinthepost.BringthemtotheBenefitOfficeandwewillgetthe
informationweneedandgivethembacktoyou.
Ifyoucannotgettheproofweneedstraightaway,donotworry.Send
theformtouswiththeproofyoudohaveandletusknowthatyouwill
besendingsomeprooflater.Ifyoudonotsendtheformtousstraight
away,you might lose money.
Change in circumstances form
Changes you must tell the                               Name:                                           Address:
Benefit Office about
Forexample:
• anyofyourchildrenleaveschoolor                ReferenceNumber:
      leavehome
• anyonemovesintooroutofyourhome,
      includinglodgersandsubtenant                   Mycircumstanceshavechangedasfollows:
• yourincomeortheincomeofanyoneliving
      withyou,includingbenefits,changes
• yourcapitalorsavingschange
• youoranyonelivingwithyoubecomesa
      student,goesonaYouthTrainingScheme,
      goesintohospitaloranursinghome,goes
      intoprison,orchangesorleavesajob
• yourrentchanges
• youmovehome
• youoryourpartneraregoingtobeaway
      fromhomeformorethanamonth
• youoranyonelivingwithyoustartswork
• youreceiveanydecisionfromtheHome
      Office,or
• anythingyouhavetoldusaboutchanges.
Thisisnotafulllist.Ifyouarenotsure,askus
foradvice.Youmusttellusaboutanychanges
inwriting-aphonecallisnotenough.
Ifyoudonottellusaboutthesechanges,you
maylosemoneyyouareentitledtooryoumay
gettoomuchbenefit.
Youmustmakesurethatyoutellusaboutany
changes.Don’t rely on someone else to pass the
message on.
Itisanoffencenottotellusaboutanychange
ofcircumstancesthatmayaffectyourbenefit.         Signature:                                                      Date:        //
Wemaytakecourtactionagainstyouandifwe
payyoutoomuchbenefit,youwillprobably                                 Please send this completed form to your local council
havetopayitback.
 Part             About you and your partner                           continued                                                                    page 

                                                             You                                                  Your partner
                                                        Letters Numbers                    Letter        Letters Numbers                    Letter
National Insurance (NI) number
You can find this on payslips or letters from social
security or the tax office. We cannot normally decide   IfyoudonothaveaNational                       Ifyourpartnerdoesnothavea
your claim if we do not have your NI number.            Insurancenumber,orcannot                         NationalInsurancenumber,or
We need to see proof of this.                           findit,tickthisbox.                              cannotfindit,tickthisbox.

If you or your partner have moved home in
the last 12 months, tell us your last address



                                                                                    Postcode                                           Postcode

Telluswhetheryouwerethehomeowner,a
privatetenant,acounciltenantoralodger
atthisaddress.
Have you or your partner claimed Housing                No                                                   No
Benefit or Council Tax Benefit before?                  Yes        Pleasetellusaboutitbelow.            Yes        Pleasetellusaboutitbelow.

Whendidyoulastclaim?                                          /       /                                          /       /

Whichcouncildidyouclaimfrom?

Whatnamedidyouusefortheclaim?

Whataddressdidyouclaimforifitisdifferent
fromabove?



                                                                                    Postcode                                           Postcode
If you have moved from this address, have you           No                                                   No
told the council you claimed from?                      Yes                                                  Yes


                                                                   We need to see proof of your identity and NI number. See the checklist at Part 16.
 Part           About you and your partner                          continued                                                                    page 

                                                          You                                                  Your partner

Have you or your partner come to live in             No                                                   No
England, Northern Ireland, Scotland, Wales,          Yes        Wewillwritetoyouaboutthis.          Yes       Wewillwritetoyouaboutthis.
the Republic of Ireland, the Channel Islands
or the Isle of Man in the last two years?

What is your nationality?

If your nationality is not British, on what                    /        /                                         /       /
date did you last enter and apply to stay in
the UK?
TheUKisEngland,NorthernIreland,
ScotlandandWales.
Are you or your partner in hospital at               No                                                   No
the moment?                                          Yes        Pleasetellusaboutitbelow.            Yes        Pleasetellusaboutitbelow.

Whendidyougoin?                                            /        /                                         /       /

Whenwillyoucomeout,ifyouknowthis?                      /        /                                         /       /

Do you or your partner get                           No                                                   No
Disability Living Allowance?                         Yes        Howmuch?Weneedtoseeproofofthis.   Yes        Howmuch?Weneedtoseeproofofthis.

                                          Care        £                                                   £

                                          Mobility    £                                                   £

Do you or your partner get                           No                                                   No
Attendance Allowance?                                Yes        Weneedtoseeproofofthis.             Yes        Weneedtoseeproofofthis.
Does anyone get Carer’s Allowance for                No                                                   No
looking after you or your partner?                   Yes        Weneedtoseeproofofthis.             Yes        Weneedtoseeproofofthis.
Have you or your partner been told that you        No                                                     No
are entitled to Carer’s Allowance even if you do   Yes          Weneedtoseeproofofthis.             Yes        Weneedtoseeproofofthis.
not receive it, because you are getting another
benefit instead? (CarersAllowancewaspreviously
knownasInvalidCareallowance).
 Part             About you and your partner                  continued                                                                         page 

                                                     You                                                Your partner

Please tick if you or your partner are:
•anapprentice                                         Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.
•onyouthtraining                                     Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.
•inlegalcustody                                      Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.
•severelymentallyimpaired                            Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.
•registeredblind                                      Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.
  l
•ong-termsickordisabled                            Weneedtoseeproofofthis.                     Weneedtoseeproofofthis.



Do you or your partner have a vehicle              No                                                 No
from a Mobility scheme?                            Yes       Wewillneedtoseeproofofthis.       Yes       Wewillneedtoseeproofofthis.



Do you or your partner pay towards the             No                                                 No
upkeep of a student?                               Yes       Howmuchdoyoupayandhowoften?       Yes       Howmuchdotheypayandhowoften?

                                                              £              every                             £              every



Are you or your partner a student?                 No        Goto Part 2.                            No        Goto Part 2.
By student we mean anyone who is attending a       Yes       Tellusifthisisfullorparttime.    Yes       Tellusifthisisfullorparttime.
course of study at an educational establishment.
                                                             Fulltime         Parttime                        Fulltime         Parttime

                                                   Pleaseprovideevidenceofyourtermtimedatesofstudyandevidenceofanystudentgrant/loanor
                                                   otherfundingyoureceive.




                                                        We will contact you if we need any more information.
                                                        See the checklist at Part 16.
 Part            About children                                                                                                               page 

Weneedtoknowaboutanychildreninyourhouseholdwhoare:
•under16,
•aged16or17andregisteredforworkoryouthtraining,or
  a
• ged16,17or18andineducationdoingacoursenothigherthanGCEA-level,SCEHigherlevelorGNVQ(advanced).

Are there any children in your     No      Goto Part 3.
household as described above?      Yes     Iftherearemorethanfourchildren,useaseparatesheetof
                                           papertotellusalltheinformationweaskforonthispage
                                           andsenditwiththeform.

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


                                     First child                   Second child                  Third child                  Fourth child

Last name

Other names

Date of birth                               //            //                //         //

What is the child’s sex?

The child’s relationship to you
The child’s relationship
to your partner
Usual address, if
different from yours




Child Benefit number
Who gets the Child Benefit
for them?
We need to see proof of this.
 Part            About children             continued                                                                                                page 

                                                  First child                  Second child                  Third child                   Fourth child
Is the child registered blind?              No                           No                            No                            No
                                            Yes        
                                                       Weneedtosee   Yes        eneedtosee
                                                                                   W                   Yes         eneedtosee
                                                                                                                  W                  Yes        W
                                                                                                                                                 eneedtosee
                                                       proofofthis.              proofofthis.                 proofofthis.                proofofthis.

Does the child get Disability               No                           No                            No                            No
Living Allowance?                           Yes        Howmuch?         Yes       Howmuch?           Yes        Howmuch?          Yes        Howmuch?

                                    Care     £                           £                            £                            £
                                            Weneedtosee              Weneedtosee               Weneedtosee               Weneedtosee
                                            proofofthis.               proofofthis.                proofofthis.                proofofthis.
                                 Mobility    £                           £                            £                            £
                                            Weneedtosee             Weneedtosee              Weneedtosee              Weneedtosee
                                            proofofthis.               proofofthis.                proofofthis.                proofofthis.
Do you or your partner pay any              No                           No                            No                            No
childminding costs for this child to
a registered childminder, a nursery         Yes        Pleasetellus   Yes        Pleasetellus    Yes         Pleasetellus   Yes        Pleasetellus
or an after-school club?                               aboutitbelow.              aboutitbelow.                aboutitbelow.              aboutitbelow.

Tellusthenameandregistration
numberoftheminder.




Howmuchdoyoupayaweek?                  £                aweek    £             aweek        £             aweek        £                 aweek
                                            Weneedtosee             Weneedtosee              Weneedtosee              Weneedtosee
                                            proofofthis.               proofofthis.                proofofthis.                proofofthis.

Howmanyweeksintheyeardo                                weeks                      weeks                      weeks                      weeks
youpaychildmindingcosts?
 Part 3            About other people who live with you                                                                                                      page 0

Now tell us about all the other people who usually live with you and your partner.
Do not tell us about people who just share a hall, bathroom or toilet with you.
If you want to tell us about more than three people, use a separate sheet of paper.
If you are sending a separate sheet of paper, tick this box.

Do any adults usually live                           No        Goto Part 4.
with you and your partner?                           Yes       Fillin thissection.
Byadultswemeanpeopleover16who
nobodygetsChildBenefitfor.                         First person                             Second person                          Third person

Last name

Other names

Date of birth                                                    //                      //                      //

Their relationship to you or your partner
Some examples are aunt, brother, daughter,
father, grandson, grandmother, stepdaughter,
joint tenant, joint owner, subtenant, lodger,
boarder or friend.
Do they get Income Support or income-based           No                                       No                                     No
Jobseeker’s Allowance or Pension Credit              Yes       Weneedtosee                                                       Yes     Weneedtosee
                                                                                              Yes     Weneedtosee
(Guarantee Credit)?                                            proofofthis.                                                                proofofthis.
                                                                                                      proofofthis.
Do they get Disability Living Allowance or           No                                       No                                     No
Attendance Allowance?                                Yes       Howmuch?                      Yes    Howmuch?                       Yes    Howmuch?

                                                      £                            aweek    £                          aweek    £                          aweek

Are they registered blind?                           No                                       No                                     No
                                                     Yes                                      Yes                                    Yes
Are they a full-time student, a                      No                                       No                                     No
student nurse, a care worker, an                     Yes                    .
                                                               Telluswhich                 Yes    Telluswhich
                                                                                                                  .                  Yes                 .
                                                                                                                                            Telluswhich
apprentice or on youth training?

                                                     Weneedtoseeproofofthis.            Weneedtoseeproofofthis.          Weneedtoseeproofofthis.
Part 3           About other people who live with you                           continued                                                              page 

                                                 First person                                Second person                        Third person
Do they pay rent or money for board and        No                                      No                                       No
lodgings to you or your partner?               Yes     Tellusaboutitbelow.         Yes       Tellusaboutitbelow.        Yes     Tellusaboutitbelow.

Howmuch?                                       £                          aweek     £                            aweek    £                          aweek

Doesthisincludemoneyforfood?              No                                      No                                       No
                                               Yes                                     Yes                                      Yes

Doesthisincludemoneyforheating?           No                                      No                                       No
                                               Yes                                     Yes                                      Yes

Do they normally work for 16 hours or          No                                       No                                      No
more a week?                                   Yes     Tellustheirearnings          Yes       Tellustheirearnings       Yes     Tellustheirearnings
                                                       beforeanydeductions.                     beforeanydeductions                 beforeanydeductions


                                                £                                         £                                   £
                                               Weneedtoseeproofoftheir          Weneedtoseeproofoftheir           Weneedtoseeproofoftheir
                                               earnings.                               earnings.                                earnings.

Are they severely mentally impaired?           No                                      No                                       No
                                               Yes                                     Yes                                      Yes

Are they in legal custody at the moment?       No                                       No                                      No
                                               Yes     Whenarethey                  Yes       Whenarethey               Yes     Whenarethey
                                                       expectedtocomeout?                      expectedtocomeout?                 expectedtocomeout?
                                                         //                         //                      //

Are they in hospital at the moment?            No                                      No                                       No
                                               Yes    T
                                                        ellusaboutitbelow.        Yes       ellusaboutitbelow.
                                                                                                 T                              Yes    T
                                                                                                                                         ellusaboutitbelow.

Whendidtheygoin?                                     //                         //                      //

Whenaretheyduetocomeout(ifyouknow)?             //                         //                      //
 Part 3           About other people who live with you                          continued                                                      page 

                                                       First person                         Second person                    Third person

Do they have any other income at all?             No                                     No                                No
Makesureyoutellusaboutallother            Yes        ellusaboutitbelow.
                                                            T                            Yes    T
                                                                                                 ellusaboutitbelow.   Yes     T
                                                                                                                                    ellusaboutitbelow.
incometheyhave.This includes any benefits or
allowances you have not told us about on this
form and interest from savings and investments.

1 Wheredoesthisincomecomefrom?               
  Howmuchisitbeforedeductions?                £                                     £                                £

2 Wheredoesthisincomecomefrom?

  Howmuchisitbeforedeductions?                £                                     £                                £

3 Wheredoesthisincomecomefrom?

  Howmuchisitbeforedeductions?                £                                     £                                £
                                                  Weneedtoseeproof                 Weneedtoseeproof            Weneedtoseeproof
                                                  oftheirincome.                       oftheirincome.                  oftheirincome.


Are any of the people who normally live           No
with you married to each other or living          Yes       Tellustheirnamesbelow.
together as if they were married? We
call these people partners.
                                                                                               isthepartnerof   

                                                                                               isthepartnerof   
Part 4           About Income Support, Income-Based Jobseeker’s
                 Allowance, and Pension Credit                                                                              page 3

Are you or your partner getting or waiting to    No      Goto Part 5.
hear about a claim for Income Support, income-   Yes     Answerthequestionsbelow.
based Jobseeker’s Allowance, or Pension
Credit?



                                                   You                                     Your partner

Are you or your partner actually getting         No                                       No
Income Support, income-based Jobseeker’s         Yes     Whendidyoustartgettingit?   Yes   Whendidtheystartgettingit?
Allowance, or Pension Credit (Guaranteed
Credit) at the moment?                                         /      /                                /    /
                                                         Nowgoto Part 11.

Are you or your partner actually                 No                                       No
receiving Pension Credit (Savings                Yes     Whendidyouclaim?              Yes   Whendidtheyclaim?
Credit) at the moment?
                                                                 /     /                               /    /

                                                         Nowgoto Part 5.


Are you or your partner still waiting to         No                                       No
hear about a claim for Income Support,           Yes     Whendidyouclaim?              Yes    Whendidtheyclaim?
income-based Jobseeker’s Allowance,
or Pension Credit?                                               /     /                               /    /

                                                         Nowgoto Part 5.
 Part            About current accounts, savings, investments and property                                                                page 4
Do you or your partner have any bank accounts, savings, investments or property in the UK or
                                                                                                       No       Goto Part 6.
abroad? Thisincludescash,overdrawnaccounts,internetaccounts,currentaccountsandsavings
accountswithabankorbuildingsociety,postofficeaccounts,premiumbonds,NationalSavings       Yes      Answerthequestionsonthispage.
Certificates,andstocksandshares.
 We must see evidence of any savings, investments or property before we can decide how much benefit you can get.
 Read the checklist at Part  to see what you can use as evidence.
                         Numberofaccounts?       Totalamount              Nameofthebank                                  Accountnumber
Money in bank                                        £
accounts                  e.g.0,1,2,3
                                                     £

                                                     £

Money in building        Numberofaccounts?       Totalamount              Nameofthebuildingsociety                      Accountnumber
society accounts                                     £
                          e.g.0,1,2,3
                                                     £

                                                     £
                         Numberofaccounts?       Totalamount              Nameofthepostofficeaccount                   Accountnumber
Money in post
                                                     £
office accounts
                          e.g.0,1,2,3               £

Premium Bonds            Howmanybonds?           Totalamount
                                                     £
                          e.g.0,1,2,3
                          Howmany?                Totalamount               Name                                              Accountnumber
Unit trusts, ISAs,
PEPs, TESSAs or other                                £
investments               e.g.0,1,2,3               £

                                                     £
                         Numberofbonds?          Totalamount              Name                                              Bondnumber
Income bonds or                                      £
capital bonds             e.g.0,1,2,3
 Part             About current accounts, savings, investments
                   and property continued                                                                                                         page 

Money or property held in trust                       £                        Wewillwritetoyouaboutthis.
                                                                               Nameofthecompanytheseareheldin.                 Numberheld.
Stocks and Shares – approximate value                 £

Stocks and Shares – approximate value                 £

Stocks and Shares – approximate value                 £
                                                     Iftherearemore,tellusabouttheothersonaseparatepieceofpaperandsenditwiththisform.
                                                     If you are sending a separate piece of paper tick this box.

Do you or your partner have any National             No
Savings Certificates?                                Yes      Pleasesendustheoriginalcertificatesasproof.Wewillreturnthecertificatestoyou.

Do any of your savings or investments include:       No
• money from the sale of a house, or                 Yes     Wewillwritetoyouaboutit.
• money from a charity?

Apart from your home, do you or your partner         No
own any other property or land in this country       Yes     Pleasetellustheaddress
or abroad?
Ifitisonamortgageoraloan,stilltickYes.                                                                            Wewillwritetoyouaboutit.
Have you or your partner received:                   No
• a Far Eastern Prisoner of War Compensation
                                                     Yes     Whatpaymentdidyoureceiveandwhoreceivedthepayment?
  payment, or
• a compensation payment made to victims of                AFarEasternPrisonerofWarCompensationpayment.                You          Your partner
  atrocities that happened during the Second
  World War?                                               Acompensationpaymentmadetovictimsofatrocities
Weneedtoknowthistomakesurewedonot                                                                                   You          Your partner
                                                             thathappenedduringtheSecondWorldWar.
countitaspartofyoursavings.
Have you or your partner received a                  No
payment from the vCJD (Creutzfeldt-Jakob
Disease) Trust?                                      Yes     Wewillwritetoyouaboutit.

Any other savings or investments.                     £                       Typeofothersavingsorinvestment

                                                      £                       Typeofothersavingsorinvestment
 Part           About being self-employed                                                                                                  page 
Are you or your partner self-employed?       No         GotoPart 7.
                                             Yes        Answerthequestionsonthispage.Youmustsendusyourtradingaccountsforthelast
                                                        financialyear.Ifyouhaveonlyrecentlysetupthebusinessanddonothaveafullyear’s
                                                        accounts,wewillneedtoseesomeotherevidenceofyourincome.Readthechecklistat
                                                        Part16toseewhatyoucanuseasevidence.Wewillwritetoyouaboutthis.
                                                  You                                                     Your partner

What kind of work do you do?


When did the business start?                           /         /                                          /         /
What is the business address?




                                                                        Postcode                                              Postcode
Do you have any business partners?           No                                                      No
                                             Yes        Tellustheirnameandaddress.              Yes        Tellustheirnameandaddress.




                                                                        Postcode                                              Postcode

How many hours a week do you usually work?
Do you get a Business Start-up Allowance?    No                                                      No
                                             Yes        Howmuchandhowoften?                      Yes        Howmuchandhowoften?
                                                             £         every                                      £         every
Do you pay into a private pension scheme?    No                                                      No
                                             Yes        Howmuchandhowoften?                      Yes        Howmuchandhowoften?
                                                             £         every                                      £         every

                                              We must see evidence of your earnings before we can decide how much benefit you can get.
                                              Read the checklist at Part  to see what you can use as evidence.
Part            About working for an employer                                                                                                   page 

Do you or your partner work for an employer?      No         Goto Part 8.
                                                  Yes        Answerthequestionsonthispage.Ifyouworkformore
                                                             thanoneemployer,tellusaboutalltheemployersona
                                                             separatesheetofpaperandsenditwiththisform.
                                                             If you are sending a separate sheet of paper, tick this box.

                                                       You                                                    Your partner

What kind of work do you do?


What is your employer’s name and address?




                                                                               Postcode                                               Postcode

When did you start this job?                                /       /                                            /       /

What is your payroll, employee or staff number?

Are you employed for a limited period?            No                                                     No
                                                  Yes        Whenwillyoufinish?                       Yes       Whenwilltheyfinish?
                                                                         /    /                                               /    /

How often do you get paid?                         every                                                 every

How much do you get paid before tax and            £                                                     £
National Insurance are taken off?

How are you paid, for example, in cash, by
cheque or straight into a bank or building
society account?

When was your last pay rise?                                /       /                                            /       /

When will your next pay rise be?                            /       /                                            /       /
Part            About working for an employer                continued                                                           page 

                                               You                                              Your partner

How many hours a week do you usually work?
Are you getting Statutory Sick Pay (SSP),     No                                              No
Statutory Paternity Pay (SPP), Adoption Pay   Yes    Whendidthisstart?                     Yes     Whendidthisstart?
or Statutory Maternity Pay (SMP) from your
employer at the moment?                                       /     /                                       /     /


Are you getting any other sick pay or         No                                              No
maternity pay from your employer at the       Yes    Howmuchandhowoften?                  Yes     Howmuchandhowoften?
moment?
                                                       £            every                            £            every

                                                      Wewillneedtoseeproofofthis.              Wewillneedtoseeproofofthis.

Do you pay into a private or company          No                                              No
pension scheme?                               Yes    Howmuchandhowoften?                  Yes     Howmuchandhowoften?

                                                       £            every                            £            every

                                                      Wewillneedtoseeproofofthis.              Wewillneedtoseeproofofthis.




                                               We must see evidence of any earnings before we can decide how much benefit you can get.
                                               Read the checklist at Part  to see what you can use as evidence.
                                               If you get tips or bonuses, tell us about these in Part 4.
 Part            About any other work                                                                                           page 

Do you or your partner do any other          No         Goto Part 9.
work at all?                                 Yes        Answerthequestionsonthispage.
Thiscouldbevoluntaryworkoranyother
work,evenifitisnotpaidwork.
                                                  You                                             Your partner

What other work do you do?


What is the name and address of the
person you do this work for?



                                                                        Postcode                                      Postcode

When did you start this work?                          /     /                                       /       /

How many hours a week do you usually work?
Do you get paid?                             No                                              No
Ifyouonlygetexpensesortips,           Yes        Tellusaboutitbelow.              Yes       Tellusaboutitbelow.
stilltickYes andgivedetails.

Howmuchdoyougetbeforeanydeductions?    £                                              £

Howoftenareyoupaid?                       every                                          every




                                              We must see evidence of any earnings before we can decide how much benefit you can get.
                                              Read the checklist at Part  to see what you can use as evidence.
 Part            About benefits and pensions                                                                                                              page 0

Have you or your partner deferred your                 No
entitlement to State Pension?                          Yes
Are you or your partner getting any benefits or  No                 Go to Part 10.
waiting to hear about benefits you have claimed? Yes                A
                                                                     nswerthequestionsonthispage.Tellusthefullrateofthebenefitsbeforeanydeductions.
Readthelistofbenefitsbelowandtellusaboutanyyouoryourpartneraregettingnoworhaveclaimed.
•AdoptionPay                                    •IncapacityBenefit                              •StatutoryMaternityPay
• AttendanceAllowance                            •IndustrialDeathBenefit                             S
                                                                                                       • tatutoryPaternityPay
•BereavementAllowance                           • IndustrialInjuriesDisablementBenefit
                                                                                                        
                                                                                                       • StatutorySickPay
•Carer’sAllowance                               •MaternityAllowance                              •WarDisablementBenefit
•ChildBenefit                                  •PensionCredit(includingSavingsCredit)         
                                                                                                       • WarPensionorWarWidow’sPension
•ChildTaxCredit                               •SevereDisablementAllowance                     •Widow’sorWidower’sBenefit
• Contribution-basedJobseeker’sAllowance
                                                  •StateRetirementPension                         •WorkingTaxCredit
•Guardian’sAllowance
Ifyouaregettingorhaveclaimedanybenefitthatisnotlisted,tell                    If you are sending a separate sheet of paper, tick this box.
usaboutitonaseparatesheetofpaperandsenditwiththeform.
                                                         You                                                       Your partner

The name of the benefit or pension

Waitingtohear                                                        Dateapplied           /      /                     Dateapplied
                                                                                                                                                    /      /
Gettingnow                                                  Howmuchandhowoften?                                  Howmuchandhowoften?

                                                              £               every                                  £            every

The name of the benefit or pension

Waitingtohear                                                        Dateapplied           /     /                      Dateapplied           /      /

Gettingnow                                                  Howmuchandhowoften?                                  Howmuchandhowoften?

                                                              £               every                                  £            every

The name of the benefit or pension

Waitingtohear                                                        Dateapplied           /     /                      Dateapplied
                                                                                                                                                    /      /

Gettingnow                                                  Howmuchandhowoften?                                  Howmuchandhowoften?

                                                              £               every                                  £            every
 Part 0            About other money coming in                                                                                                             page 

Do you or your partner have any money                No        Goto Part 11.
coming in (or expect to have some money              Yes       Answerthequestionsonthispage.
coming in) that you have not already told us                   YoudonotneedtotellusaboutpaymentsfromtheIndependentLivingFund,theEileen
about on this form? Thisincludes:                            TrustortheMacFarlaneTrust.


•   Occupationalpensions                                                           •   EquityReleaseschemes
•   Workpensionsandprivatepensions                                              •   HomeIncomePlans
•   Annuities                                                                       •   Maintenanceorchildsupportforyou,yourpartneroranyofthe 
•   Anycashpayments                                                                   childrenyouhavetoldusaboutonthisform
•   Anymoneyyougetfrompeoplelivinginyourhouseasboarders,              •   Moneyfromatrustfund
    lodgersorsubtenant                                                            •   Studentgrantorloan
                                                                                     •   Trainingallowances




                                                           Other money                           Other money                        Other money 3

What is the money for?




Who gets it?


How much do they get?                                 £                                         £                                 £
How often?                                            every                                     every                             every

How is it paid?                                        

When did they start getting this income?                         //                         //                  //

When is the income likely to go up?                              //                         //                  //
Part 0          About other money coming in            continued                                                              page 

                                              Other money                     Other money                    Other money 3
Does anyone owe money to you or             No                               No                              No
your partner?                               Yes    Tellusaboutitbelow.   Yes   Tellusaboutitbelow.   Yes   Tellusaboutitbelow.

Whatfor?




Howmuch?                                    £                               £                              £

Whoisitowedto?

Are you expecting to get any money in the   No                               No                              No
next 12 months?                             Yes    Tellusaboutitbelow.   Yes   Tellusaboutitbelow.   Yes   Tellusaboutitbelow.
Forexample,aredundancypaymentora
paymentinsteadofnoticeorholiday.
Whatfor?




Howmuch?                                    £                               £                              £




                                             We must see evidence of any money coming in before we can decide how much benefit you can
                                             get. Read the checklist at Part  to see what you can use as evidence.
Part           About where you live                                                                                         page 3

Do you jointly own your home?              No
                                           Yes   Whowith?                                                              Goto Part 14.
Do you own your home or have a mortgage?   No
                                           Yes   GotoPart 14
Do you pay rent to the Borough of Poole?   No     FillinthisSection
                                           Yes    GotoPart 14

What sort of building do you live in?
Tick one box only.                         Detachedhouse                            Flatinahouse         Caravan,mobile
                                                                                                             homeorhouseboat
                                           Semi-detachedhouse                       Flatinablock         Boardandlodgings

                                           Terracedhouse                            Flatoverashop        Hotel

                                           Maisonette                                Bedsitorroomsor     Residentialnursinghome
                                                                                     astudioflat
                                           DetachedBungalow                         Hostel                  Residentialcarehome

                                           Semi-detachedBungalow                    Other- give details

Does your home have central heating?       No
                                           Yes

Does your home have a garage?              No
                                           Yes

Does your home have a parking space?       No
                                           Yes

How many floors are there?                  

Do you and your household occupy only      No
part of the building you have ticked?      Yes    Whereinthebuildingdoyoulive?

                                                  Atthefront           Inthemiddle         Attheback
 Part            About where you live           continued                                                           page 4

Which floors do you live on?                       
Forexample,groundfloor,firstfloor.

How many rooms are there in the building?         In the whole                 Just for you and   That you share
                                                  building                     your household     with other people

Livingrooms

Bedsittingrooms

Bedrooms

Bathroomsorshowerrooms

Toilets

Kitchens

Otherrooms


Do you use your home for business?                No
                                                  Yes

Do you have a main home somewhere else?           No      GotoPart 12
Ifyourmainhomeissomewhereelseinthe       Yes     Tellusaboutitbelow.
UKorabroad,tickYes,evenifyoudonotpay
rentforit.

Whatistheaddress?




                                                                      Postcode

Doyoupayrentontheaddressabove?             No
                                                  Yes    Howmuch?        £
Part            About rent                                                                                                                 page 
Do you pay rent or a site fee for your home?        No      Goto Part 13
TickYesifyoupayrentbutyoualreadyget
HousingBenefit.                                    Yes    Completethesectionbelow.

What is your landlord’s full name and
business address?
Bylandlordwemeanthepersonor
organisationwhoownsthepropertyyou
livein.
                                                                            Postcode
If your landlord has an agent, tell us their full
name and address.
Byagentwemeanthepersonororganisation
youactuallypayyourrentto.
                                                                            Postcode
Are you or your partner related to your
                                                    No
landlord or agent, or to your landlord’s partner
or the agent’s partner?                             Yes     Who?                                                             Relationship?
Relatedincludesrelatedthroughmarriage/                                                               ismylandlord’s
civilpartnership,evenifthemarriage/civil                                                                               
                                                                                                         oragent’s
partnershiphasended.Someexamplesare
ex-wife,ex-husband,aunt,brother,daughter,
father,grandson,grandmother,son-in-lawor
stepdaughter.


When did you start renting your home?                       //
When did you move to this address?
Ifyouhavenotmovedinyet,telluswhenyou             //
expecttomovein,thentelluswhenyouhave
actuallymovedin.
What sort of tenancy do you have?
Forexample,shorthold,assuredtiedrentor
somethinglikethis.
How long is the tenancy for?                                //      to          //
What is the property let as?                        Furnished
Ticktheboxthatapplies.
                                                    Partlyfurnished
                                                    Unfurnished
 Part           About rent         continued                                                                                         page 


How much is your rent before Housing
                                                      £                  every
Benefit and how often should it be paid?
Forexample,everyweek,everyfortnight,
everyfourweeks,monthly.                            We must see evidence of your rent and tenancy before we can decide how much benefit you can
                                                      get. Read the checklist at Part  to see what you can use as proof.

Does anyone else share the rent with you and         No
your partner?                                        Yes    Tellusthedetailsbelow.


Tellustheirnamesandtheirrelationshiptoyou
andyourpartner.



                                                      


Howmuchoftherentdotheypayandhow             £                  every
often?
For example, every week, every fortnight, every
four-weeks, monthly.


Has your rent changed in the last 12 months?         No
                                                     Yes    S
                                                             endusproofofthedateitchangedandhowmuchitchanged.


When is the next rent increase due?                         //

Has your rent been registered as a fair rent by      No
a rent officer?                                      Yes    PleasesendusthenoticeofregistrationformRO5.

Do you have any weeks when you do not                No
have to pay rent?                                    Yes    Howmanyinayear?

Are you behind with your rent?                       No
                                                     Yes    B
                                                             yhowmanyweeks?
 Part            About rent         continued                                                                      page 

Who has to pay the Council Tax bill               Youoryourpartner
for your home?
                                                  Yourlandlord
Ticktheboxthatapplies.
                                                  Someoneelse         Telluswhoitis.



Does your rent include money for the following?
Meals                                             No
                                                  Yes     Howmuch?          £              every

                                                                           Forwhichmeals?           Breakfast
                                                                           Please tick.               Lunch
                                                                                                      Eveningmeal
Waterauthoritycharges                           No
                                                  Yes     Howmuch?          £              every

Heating                                           No
                                                  Yes     Howmuch?          £              every

Lighting                                          No
                                                  Yes     Howmuch?          £              every

Hotwater                                         No
                                                  Yes     Howmuch?          £              every

Fuelforcooking                                  No
                                                  Yes     Howmuch?          £              every

Laundry                                           No
                                                  Yes     Howmuch?          £              every

Cleaningroomsorwindows                         No
                                                  Yes     Howmuch?          £              every
 Part           About rent        continued                                                                                           page 

Gardening                                          No
                                                   Yes       Howmuch?      £             every

Garageorparkingspace                            No
                                                   Yes       Howmuch?      £             every
                                                             Doyouhavetorentthegarageas   No
                                                             partofyourtenancyagreement?      Yes
Personalcareandgeneralcounselling            No
andsupport                                        Yes       Howmuch?      £             every

Do you pay any service charges separate from       No
your rent, for example, for cleaning or lighting   Yes       Howmuch?      £             every
in shared areas, an alarm system, a warden,
general counselling or support, meals, or lift               Whatfor?
maintenance?

Are you living away from home at the moment?       No
                                                   Yes       Tellusaboutitbelow.

Whyareyounotlivingathome?
                                                   
Whendidyoulastliveathome?                               /       /

Whendoyouexpecttogobackhome?                           /       /

Whatistheaddressofwhereyouare
livingatthemoment?



                                                                            Postcode

Haveyousubletyourhome?                         No
                                                   Yes       Wholives
                                                             therenow?

                                                       We must see evidence of your rent and tenancy before we can decide how much benefit you can
                                                       get. Read the checklist at Part  to see what you can use as evidence.
 Part 3          How you will be paid and the choices you have                                                                       page 

• If you are awarded Housing Benefit, in most cases you can choose where to have your money paid.
  Depending on your circumstances, we can arrange to pay your money:
        - straight into a bank, building society, GIRO account or National Savings Bank account
        - by cheque or
        - direct to your landlord.
• If you are awarded Council Tax Benefit, we will pay this into your Council Tax account.

 SECTION A
When would you like your Housing Benefit to be paid?                                                          Everytwoweeks(inarrears)
                                                                                                              Everyfourweeks(inarrears)

 SECTION B - Tenants of Housing Associations or Registered Social Landlords.
If you are not a tenant of a Housing Association or a Registered Social Landlord please complete Section C.
Wecanpayyourrentdirecttoyourlandlordorwecanpayyourmoneystraightintoabank,building
society,GiroaccountorNationalSavingsBankAccount.
Ifyouwouldlikeustopayyourlandlorddirectpleasetickthisbox.
Ifyouwouldlikeustopayyourbenefittoyourbankaccount,pleasetickthisboxandcomplete
Section Doverleaf
Ifyourequireustopayyoubycheque,pleasetickthisboxandexplainwhyyourequirepaymentby
chequeinPart 14.
 SECTION C - Private Tenants
UndertheLocalHousingAllowancerulesyourhousingbenefitwillbepaidstraightintoyourbank,
buildingsociety,GiroaccountorNationalSavingsBankAccount.
PleaseprovidedetailsoftheaccountintowhichyouwantyourbenefitpaidbycompletingSection D
overleaf.Please proceed to Section D unlessyour circumstances are exceptional.
If your circumstances are exceptional:
• ifyourequireustopayyourlandlord,pleasetickthisboxandwewillsendaformyoumustcomplete,
    explainingwhypaymentshouldbesenttoyourlandlord
• orifyourequireustopayyoubycheque,pleasetickthisboxandexplainwhyyouconsideryouneed
    tobepaidbychequeinPart14.
Part 3         How you will be paid and the choices you have                         continued                                     page 30

SECTION D
Please note: Housing Benefit payments cannot be made into a Post Office Card Account you may hold for Job Seeker Allowance, Income Support and
Pension payments. These accounts only accept payments made by the Department for Work and Pensions or Her Majesty’s Revenues and Customs.



  Payment into an account                                                            Building society savings account –
                                                                                     not a cheque or mortgage account
      What name or names is the                                                     Nameof
      account in?                                                                   buildingsociety

                                                                                    Accountnumber
      Please tick one box only to say what type of account you want
      your money paid into. Then fill in the details of the account.                Rollnumber
       Bank or building society cheque account or bank deposit account –
       not a mortgage account                                                        GIRO account

      Nameofbankor                                                              Accountnumber
      buildingsociety
      Sortcode
                                                                                     National Savings Bank investment account –
      Accountnumber                                                                 not an ordinary account
      Typeofaccount–forexample,
      adepositorcurrentaccount                                                  Accountnumber
 Part 4          Anything else you need to tell us                                               page 3

Please use this space to tell us anything else    If you are sending any separate sheets of
you think we should know about.                   paper with this form, tell us how many.
Useaseparatesheetofpaperandattachitto
thisformifyouneedto.                         Iamenclosingafilled-inPaying benefit to
                                                  your landlordform.
                                                  Iwillsendyouafilled-inPaying benefit to
                                                  your landlordformlater.
Part           Backdating                                                             page 3

WecanusuallyawardbenefitfromtheMondayafterthedaywereceiveyourclaim.
Sometimeswecanpaybenefitfromanearlierdateifyouhaveagoodreasonfor
notclaimingearlier.Ifyouwantustoconsiderpayingyourbenefitfromanearlier
date,telluswhenyouwantbenefitfromandwhyyoudidnotclaimearlier.

Date you want to claim benefit from                          /       /

For this earlier period, were your circumstances   No
the same as on this form?                          Yes

Tell us why you have not claimed before:
Part             Checklist                                                                                                                 page 33
Pleaseticktosaywhatevidenceyouaresendingwiththisform.We        • Evidence of earnings
mustseeoriginal documents,notcopies.                                      We also need this for other adults who form part of your household.
Pleasedonotsendvaluableitemsthroughthepost.Ifyoucan,bring        T
                                                                              hismeansyourlastfivepayslipsifyouarepaideveryweek,your
themintoourreception.Wewilltakethedetailsweneedandgive           lastthreepayslipsifyouarepaideverytwoweeks,oryourlasttwo
youthedocumentsbackstraightaway.Ifyoucannotgetintothe             payslipsifyouarepaideverymonth.YoucanusetheEmployers
office,phoneusformoreadvice.                                             Certificateattheendofthisformtoprovideproofaboutyour
                                                                              earnings.Wewillcontactyouremployerifyoudonotprovidethis
If you do not provide all the evidence we need, we might not be               information.
able to pay you any benefit. We need the same evidence for your
partner, if you have one.
                                                                            • Evidence of self employed earnings
Ifyoucannotsendtheevidenceweneedatthemoment,sendthe
                                                                              Ifyouoryourpartnerareself-employed,weneedtoseeyour
formbacktousnowandsendtheevidencelater.Wecanstartto
                                                                              accountsforthelastfinancialyearor,ifyouhavebeentrading
processyourclaim,but we will not be able to pay you any benefit
                                                                              forlessthansixmonths,detailsofyourtradingrecordssofar.
until we have all the evidence.
                                                                              Alternativelyyoucancompleteaselfemployedassessmentform.
• Evidence of identity                                                        If you would like a form please tick the box.
  S
  uchasabirthcertificate,marriagecertificate,passport,National   • Evidence of other income
  Insurancenumbercard,medicalcard,drivinglicence,UKresidence
                                                                              We also need this for other adults who form part of your household.
  permit,EECidentitycardorrecentgasorelectricitybill.Wemay
  needtoseeseveralofthesedocumentsforeachperson.                     S
                                                                              uchaspensionslipsfromaformeremployeroraletterfromthe
                                                                              courtshowinghowmuchmaintenanceyouaregetting.Weneedto
                                                                              seeevidenceofanymoneypeoplepayyouforboardandlodgings.
• Evidence of your address
  S
  uchasarecentgasorelectricitybilloraTVlicence.
                                                                            • Evidence of benefits, allowances or pensions
                                                                              We also need this for other adults who form part of your household.
• Evidence of National Insurance number
                                                                              S
                                                                              uchascurrentawardnoticesorlettersfromsocialsecurityorinland
  S
  uchasaNationalInsurancenumbercard,payslipsorlettersfrom
                                                                              revenueconfirminghowmuchyouget.Ifyoudonothaveevidence,
  socialsecurityorthetaxoffice.
                                                                              letusknowstraightaway.Pleasedonotsendorderbooksthrough
                                                                              thepost.
• Evidence of capital, savings and investments
  S
  uchasallyourbank,buildingsocietyorpostofficebooks,full      • Evidence of private rent and tenancy
  bankstatements,orcertificatesforpremiumbonds,National
                                                                              S
                                                                              uchasarentbook,rentreceipts,atenancyagreementoraletter
  SavingsCertificates,ISAs,stocks,sharesandunittrusts.Weneedto
                                                                              fromyourlandlord.
  seeevidenceofanyinterestordividendsyougetoninvestments
  andsavings.Theevidenceyousendmustshowdetailsforatleast
  thelasttwo months, or six months if you are self employed.              • Evidence of other money paid out
                                                                              S
                                                                              uchaslettersaboutstudentgrantsormaintenanceagreementsor
                                                                              receiptsfromregisteredchildcarers.
                                                                            Make sure you read and sign the declaration on Page 34
 Part           Declaration                                                                                                                      page 34

Even if someone else has filled in this form for you, you must sign this declaration if you can.
If you have a partner, getting them to sign this form should allow us to process your claim more quickly, but they do not have to sign.

Please read this declaration carefully before you sign and date it.              •     I understand thatyoumayuseanyinformationIhaveprovidedin
•  declarethattheinformationIhavegivenonthisformiscorrect
    I                                                                                  connectionwiththisandanyotherclaimforsocialsecuritybenefits
    andcomplete.                                                                      thatIhavemadeormaymake.Youmaygivesomeinformation
                                                                                       tootherorganisations,suchasgovernmentdepartments,local
•    understandthatifIgiveinformationthatisincorrector
    I                                                                                  authoritiesandprivate-sectorcompaniessuchasbanksand
    incomplete,youmaytakeactionagainstme.Thismayinclude                      organisationsthatmaylendmemoney,ifthelawallowsthis.
    courtaction.                                                                •     I
                                                                                        knowthatImustletyouknowinwritingaboutanychangeinmy
•   I agreethatyouwillusetheinformationIhaveprovidedtoprocess              circumstanceswhichmightaffectmyclaim.
    myclaimforHousingBenefitorCouncilTaxBenefit,orboth.You
    maychecksomeoftheinformationwithothersourcesasallowed
    bythelaw.

Signature of person                                                                  Partner’s signature
claiming


Date                                 /        /                                      Date                              /       /

If this form has been filled in by someone other
than the person claiming
Pleasetelluswhyyouarefillinginthisformfor
thepersonclaiming.
                                                       I declarethatasfaraspossible,Ihaveconfirmedwiththeperson
                                                       claimingthattheanswersIhavewrittenonthisformarecorrect.

Name of the person who filled in the form

Signature



Relationship to the person claiming

Date                                                            /        /
Sharing information with your landlord                                                                                                        Tear-off 1

Sharinginformationwithyourprivatelandlordcouldhelpusdealwith      Ifyougiveuspermission,wewouldbeabletotellyourlandlordwhether:
yourclaimmorequicklyandreducetheriskofyoufallingbehindwith
                                                                             •    ouhaveclaimedorrenewedyourclaimfor
                                                                                 y
yourrentbecauseofyourclaimbeingdelayed.
                                                                                 HousingBenefit,
Wemayneedtoconfirminformationwithyourlandlordbeforewe
                                                                             •   wehavemadeadecisiononyourclaim,or
canmakeadecisiononyourclaim,forexample,thestartdateofyour
tenancy.Inthesecircumstances,wecancontactyourlandlordwithout       •   weneedmoreinformationtomakeadecisiononyourclaim,and
yourpermission.                                                                 whatthatinformationmaybe.
UndertheDataProtectionAct1998weneedyourpermissiontodiscuss       We will not give your landlord any information about:
anythingelse.
                                                                             •   your personal or household circumstances, or
                                                                                 your financial circumstances.
                                                                             Youcanwithdrawyourpermissionatanytime.
                                                                             It will not affect your claim if you do not give us permission to discuss
                                                                             your claim with your landlord.
                                                                             Ifyouwanttogiveuspermissiontodiscussyourclaimwithyourlandlord,
                                                                             pleasesignbelow.

I give my local council permission to share information about the progress
of my Housing Benefit claim with my landlord or their representitive.



Signature                                                                    Address




Full name                                                                                Postcode
(inCAPITAL
LETTERS)

Date                   /       /
 Paying benefit to your landlord if you are a tenant of a
 Housing Association or Registered Social Landlord
Ifyouwantustopayyourbenefitstraighttoyourlandlord,youmustsignthisdeclaration.
 Your declaration
PleasepaymyHousingBenefitstraighttomylandlord.
    I
•  understandthatImustalwaystellyouaboutanychangeinmycircumstances.
    I
•  understandthatifIdonottellyouaboutanychangeofcircumstancesandyoupaymetoomuchbenefitbecauseofthis,Imayhavetopayback
    theextrabenefit.
    I
•  understandthatImaybeprosecutedifIdonottellyouaboutanychangeofcircumstances.
Signature                                                                                          Address




Full name(inCAPITALLETTERS)
                                                                                                      Postcode

                                                                                                    Date
                                                                                                                 /   /
Your landlord's declaration
IagreetoacceptHousingBenefitpaymentsforthetenantnamedabove.
I understand that by law:
    I
• musttellyoustraightawayifIfindoutaboutanychangeinthetenant’scircumstances
    y
•  oucanstoppayingbenefittomeifIdonottellyouaboutanychangeofcircumstances
    I
• canbeprosecutedifIacceptHousingBenefitwhichIknowIamnotentitledto,and
• ifyoupaymetoomuchHousingBenefitforanytenant,Imayhavetorepayit.YoucantaketheamountofoverpaidbenefitfromthebenefitIget
    foranyothertenants.Thiswillnotaffecttheirrent.
 Signature                                                                                          Address




Full name(inCAPITALLETTERS)
                                                                                                      Postcode

                                                                                                    Date
                                                                                                                 /   /
Please return this form to your tenant
Employer’s Certificate of Earnings                                                                                                                 Tear-off 2

Note to claimant                                                                 Note to employer
Youshouldonlyusethisformifyouareunabletoprovidepayslipsas          Pleasecompletetheboxesbelowandsignthedeclaration.Pleasegive
proofofemployment.Pleasecompleteyournameandaddressandthen            detailsofyouremployeeslast5weeksor3fortnightsorlast2months
givetheformtoyouremployertocompleteyourdetails.Please return          paydetails.Please then return the form to the employee.
the form as soon as possible to the local authority benefits office.
                                                                                                           Letters Numbers                         Letter
                                                                                 National Insurance
Claimants name                                                                   Number
Address
                                                                                 Payroll number


                                                                                 Start date            /      /          End date              /       /
                           Postcode
                                                                                                           Date of next pay rise               /       /

 Wage details for the last consecutive  weeks, 3 fortnights or  months.                                Averageweeklyhoursworked
                                                                                              Pension
Date                           Grosspay         IncomeTax            NationalInsurance     contribution       TaxCredits         Takehomepay
           /       /             £                  £                    £                     £                     £                     £

           /       /             £                  £                    £                     £                     £                     £

           /       /             £                  £                    £                     £                     £                     £

           /       /             £                  £                    £                     £                     £                     £
           /       /             £                  £                    £                     £                     £                     £

 Totalssofarthisyear         £                  £                    £                     £                    Uptoandincluding
                                                                                                                    week/month

 MethodofPayment(e.g.cash,cheque,BACS)                                     FrequencyofPayment(e.g.weekly,monthly)

Ideclarethisrecordistrueandcomplete.IamawarethatifIgiveincorrectinformationImaybeprosecuted.                     Companystamp


Employer’s                                                            Position
signature                                                             held

Full name
(inCAPITAL                                                          Date                /        /
LETTERS)
 Certificate of Rent                                                                                                                   Tear-off 3
 To the Tenant                                                               Doestherentinclude:(pleasetickasappropriate)
Pleasehandthisformtoyourlandlordandaskhimtocompleteitand
returnittoyou.ThecompletedformshouldthenbesenttotheCouncil    Watercharges             No
assoonaspossible.                                                                                                               £
                                                                                                       Yes    Howmuch?
 To the Landlord
Pleaseassistyourtenantbycompletingthisformandreturningittothe   Electricity               No
tenantassoonaspossible.                                                                                                        £
                                                                                                       Yes    Howmuch?
Name of tenant:

Address of tenancy:                                                          HotWater                 No
                                                                                                       Yes    Howmuch?           £


                                                                             Heating                   No
                            Postcode
                                                                                                       Yes    Howmuch?           £
Date tenancy started:                  /     /

How much is the                                       Howoften              Lighting                  No
                            £
tenant liable to pay?                                                                                  Yes    Howmuch?           £


                                                                             Cooking                   No
Are there any             No
rent free weeks?                                                                                       Yes    Howmuch?           £
                          Yes    IfYeshowmany?

Is the rent paid          No                                                 Meals                     No
up to date?
                          Yes                                                                          Yes    Howmuch?           £
                          IfNostatedetails.
                                                                                                       IfYESBreakfastonly
                                                                                                       Lessthan3mealsaday

Is the accommodation      No                                                                           3ormoremealsaday
furnished?                                                                   Anyotherservices?
                          Yes
                                                                             (pleasespecify)
How much notice is                                         weeks/months
the tenant required
to give?
 Certificate of Rent           continued



Name of landlord

Address of landlord




                           Postcode


Do you own the           No
property?
                         Yes

If NO are you a          No
Licensed tenant?
                         Yes

Are you related          No
to the tenant?           Yes     Who?                                                                    Relationship?

                                                                           ismylandlord’soragent’s



The information given on this form is, to the best of my knowledge and belief, true and correct.


Landlord’s signature



Full name
(inCAPITALLETTERS)


Date                                  /    /

								
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