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Housing and Council Tax Benefit Claim

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					              Housing and Council Tax Benefit Claim
 Benefits Service PO Box 12 County Hall Cross Street Beverley East Riding of Yorkshire HU17 9BD
   Tel: (01482) 394799 Email: benefit.assessments@eastriding.gov.uk www.eastriding.gov.uk/benefits


Use this form to claim Housing Benefit and Council Tax Benefit if you do not already have a claim for benefit with East Riding of Yorkshire
Council. Please make sure you answer all the questions. Answer all Yes or No questions by putting a ‘✓’ in the relevant box. You will find
detailed notes to help you fill in this form on the next page.

Supporting evidence
If you fill in this form correctly with all the evidence required, we will process your claim more quickly. Original documents must be provided. Photocopies are not
acceptable. However, if you do not have all the evidence required, please do not delay returning this form as you can normally only get benefit from the week after
we receive your claim. We will contact you if we need to ask you for more evidence. It is important that you do not delay making your claim.

About Housing and Council Tax Benefit
Housing Benefit may be able to assist you with your rent payments but cannot pay for some services included in your rent. Council Tax Benefit can assist you with your
Council Tax payments. You can also use this form to make a claim for free school meals.

Second Adult Rebate
Second Adult Rebate may be able to help you with your Council Tax payments if you live with someone who is on a low income.


  Your name and address (for which you are claiming)                                            Office use only

                                                                                                Date to customer
  Name
                                                                                                Date to contact
  Address
                                                                                                Date received at
                                                                                                designated office
                                                               Postcode

  Telephone
                                                                                                Claim number

                                                                                                                                                               PD1140
                                                              Housing Benefit and Council Tax Benefit Claim

About this form                                                                 Proof
We have designed this form to be easy to fill in. It may look rather long, but   We still need to see proof of some of the things you write about in this form.
there needs to be enough questions to make sure that everyone who claims        Where evidence is required pages are marked with this icon . If you are
gets the right amount of benefit. Every part starts with a question to help      unsure whether to send proof of something, please contact us. We will tell
you decide whether you need to fill in that part. Your views on how we can       you what we need to see. Remember that we cannot pay you benefit until
improve this form are welcome. Please tell us in Section 15.                    we have seen the evidence we need.
If you need help to fill in the form                                             We do not recommend that you send valuable documents through the post.
If you need any help please contact us. Our contact details are shown on        These can instead be taken to your local Customer Service Centre (details
page 33 of this form. This includes our telephone number and the addresses      of which are on page 33 of this form) where they will be photocopied and
of our Customer Services Centres.                                               returned to you immediately.
About Housing Benefit and Council Tax Benefit                                     Filling in this form
Housing Benefit can pay all or part of your rent. It may also give you some      We will scan this form into our computer system so please use black ink. Do
extra money towards services you have to pay your landlord for, like            not use pencil and do not use correction fluid or tape - otherwise it can look
children’s play areas and cleaning shared areas. Council Tax Benefit can pay     as if someone else has changed the form after you completed it. Answer Yes
all or part of your Council Tax. It cannot help with water charges.             or No questions by placing a ‘✓’ in the relevant box - do not use a cross ‘✗’
Second Adult Rebate                                                             because it can make your answers look confusing and delay the processing
Second Adult Rebate is for people who may not qualify for Council Tax           of your claim.
Benefit based on their own income or capital, but who share their home           What to do next
with someone who:                                                               When you have filled in the form and signed it, please send it with the proof
•   is 18 or over;                                                              we need to the Benefits Service address on page 1 or you can send or hand
•   is on a low income, and;                                                    deliver it to one of the contact addresses on page 33 where we can copy
•   does not pay you rent;                                                      them.
•   and is not your partner;                                                    If you do not have the proof we need straightaway, please do not delay
and as a result of that person living with them the Council Tax payer is        returning this form as you can normally only get benefit from the week
prevented from getting a Council Tax discount. If you only want to claim        following your claim. We will write to you if we need to ask you for more
Second Adult Rebate, just fill in parts 1, 3 and parts 15 to 19 of this form.    evidence.
                                                                                Remember that we must see original documents as proof.
                                                                                Photocopies are not acceptable.
    A Claim form for Housing Benefit and Council Tax Benefit                                                                                                     Part 1        Page 3

If you are just claiming Second Adult Rebate, you only need to fill in parts 1, 3 and 15-19 of this form

Are you (please tick one box)       a council tenant?       a private tenant?    a housing association or social landlord tenant?             an owner occupier?            other?


                                                                      About you and your partner


Do you have a partner who normally lives with you?                  No          Yes     If you have a partner, you must complete this form together. Complete all the
By partner we mean someone of the opposite or same sex                                  questions about you and your partner. Your partner should also read and sign the declaration
who:                                                                                    on page 29.

•     Is married to you, or who lives with you as if you are
      married, or
•     Is your civil partner, or who lives with you as if you are
      civil partners.


                                                                      You                                                        Your partner


Surname or family name


Other names


Any other names you or your partner have used


Title (Mr, Mrs, Miss, Ms, other)                                    Mr          Mrs        Ms             Miss                 Mr             Mrs            Ms            Miss

                                                                    Other                                                      Other
 Page 4       Part 1                                           About you and your partner continued


                                                               You                                                Your partner



What date did you move to this address?                                    DD / MM / YYYY                                    DD / MM / YYYY


Phone number (This may help us pay your claim quicker.)


If the number above is for the person who has helped
you claim benefit, please enter their name.


Email address (This may help us pay your claim quicker.)


Date of birth                                                              DD / MM / YYYY                                    DD / MM / YYYY


Gender                                                        Male        Female                                Male        Female



National Insurance (NI) Number
                                                               Letters   Numbers   Numbers   Numbers   Letter    Letters   Numbers   Numbers   Numbers   Letter
You can find this on payslips, your P60 or P45, or letters
from the Tax Office, Department for Work and Pensions or
the Tax Credits office. We cannot normally pay your claim if
we do not have your NI number. We need to see proof of
this.
If you or your partner do not have a National Insurance
number, or cannot find it, please tick this box.

Are you or your partner registered blind?                     No          Yes                                   No          Yes


                                                               We must see proof of National Insurance number(s). Read the checklist in part 19
                                                               of this form to see what you can use as evidence.
  About you and your partner continued                                                                                                                       Part 1          Page 5


                                                            You                                                               Your partner


Have you or your partner claimed Housing Benefit           No          Yes                                                   No          Yes
or Council Tax Benefit before?

Please provide the last address where you and your
partner lived before you moved to the address you
are claiming for.




Postcode

Please tell us if you were either a homeowner, private
tenant or council tenant at this address.

What is your nationality?

Have you or your partner ever lived outside the           No          Yes                                                   No          Yes
British Isles?
By “British Isles” we mean the UK, Republic of Ireland,
Channel Islands and the Isle of Man.
If yes, when did you and/or your partner most
recently come to live in the British Isles?

Are you or your partner a student?                        No          Yes      Tell us if this is full time or part time.   No          Yes      Tell us if this is full time or part time.

                                                          Full time         Part time                                       Full time         Part time

Do you or your partner make a contribution                No          Yes                                                   No          Yes
towards a student’s loan, grant or living expenses?
                                                            We will contact you if we need any more information
    Page 6     Part 2                                               About your children                                                                              Page 6

We need to know about any children who live with you and are:
                                                                                      If you or your partner get Child Benefit,
•     Aged under 16, or                                                               please write your Child Benefit number
•     Aged 16 or over and you or someone else receives Child Benefit for them.         in this box, if known.
Details of children who are the responsibility of you or your partner.                Your Child Benefit reference number beginning “CHB can be found at the top right of your
                                                                                      Child Benefit letters and on your bank statement.

If you do not have any children living with you go to part 3. Use this part of the form to provide details of up to four children. If you have more than four children living
with you, please provide the same information for each additional child in part 15.

                                                                    First Child                                              Second Child


Child’s surname


Child’s other name(s)


Child’s gender and date of birth                                  Male      Female          DD / MM / YYYY                 Male      Female          DD / MM / YYYY

Is there another address where the child stays or lives,
apart from the address you are claiming for?
Please provide details and say why the child stays there
(e.g. shared custody).

Who gets Child Benefit for this child?

Do you or your partner receive any fostering or                   No       Yes                                             No       Yes
adoption payments for this child?

Is this child registered blind?                                   No       Yes                                             No       Yes


Does this child get Disability Living Allowance?                  No       Yes                                             No       Yes
Answer Yes even if someone else receives Disability Living
Allowance on behalf of the child.
                                                                    We must see proof of Child Benefit
 About your children                                                                                                               Part 2    Page 7

                                                            Third Child                                      Fourth Child

Child’s surname

Child’s other name

Child’s gender and date of birth                           Male     Female           DD / MM / YYYY         Male   Female        DD / MM / YYYY

Is there another address where the child stays or lives,
apart from the address you are claiming for?
Please provide details and say why the child stays there
(e.g. shared custody).
Who gets Child Benefit for this child?

Do you or your partner receive any fostering or            No      Yes                                      No     Yes
adoption payments for this child?
Is this child registered blind?                            No      Yes                                      No     Yes

Does this child get Disability Living Allowance?           No      Yes                                      No     Yes

 About paying for child care

Do you or your partner pay for a registered
                                                            For which of your children?
childminder, a nursery or an after-school club?
No      Go to page 8   Yes                                  What is the name, address and              1.                   2.
                                        £
                                                            OFSTED number (if known) of
How much do you/your partner pay?                           the provider(s)?
                                        every               If you use more than two child care
                                                            providers, please use part 15 to tell us
Do you/your partner only pay during     No      Yes         about the others.
school term time?
                                                            If you provide evidence of child care costs we may be able to increase the amount of
                                                            benefit you receive. Read the checklist in part 19 of this form to see what you can
                                                            use as evidence.
 Page 8         Part 2                                               Free School Meals                                                              Page 6

Only families who meet the following criteria will be eligible for free school meals:

• You receive Jobseekers Allowance (Income-based) or Income Support or Pension Credit (Guarantee Credit) or Employment and Support Allowance (Income-related);
  or

• You receive Child Tax Credit and do not receive Working Tax Credit, and you have a low income.

Do you wish to claim for free school meals? Please tick the required option.

No        Yes

Please give the name of the school that each of your children attend:




 Child                                                                                  School
  About other people who live with you                                                                                                                                                      Part 3       Page 9
Tell us about other people that live with you: For example any other adult or young person who lives with you.
To tell us about more than three people, use part 15.
Is there anyone else who normally lives with you?          No        Go to part 4 Yes        Fill in this part
                                                                                First Person                                  Second Person                                Third Person

Surname

Other name(s)

Relationship to you
Parents, son, daughter, care worker, friend, foster child, boarder or sub-
tenant. Boarders are people, not close relatives, who pay rent that includes
an amount for meals. Sub-tenants are people, not relatives, who pay rent
that does not include an amount for meals.
Is this person the partner of anyone else who lives                            No           Yes        Partner of            No          Yes         Partner of           No           Yes           Partner of
with you? If so, say who.
By “partner’’ we mean spouse, civil partner or living together as
if they were a spouse or civil partner.
Do they pay rent money for board and lodgings to you                           No           Yes         £                    No         Yes          £                    No          Yes         £
or your partner? If so, how much? Please tick no if this is
                                                                                                        per week                                     per week                                     per week
paid by an adult friend or relative.
Does this include food?                                                        No           Yes                              No         Yes                               No          Yes

Are they a joint owner or joint tenant who shares                              No           Yes                              No         Yes                               No          Yes
the rent or Council Tax with you?
You do not need to answer any further questions in part 3 about a person who pays you rent or is a joint tenant with you.

Date of birth                                                                             DD / MM / YYYY                            DD / MM / YYYY                                  DD / MM / YYYY

Do they get any of the following benefits:                                      No           Yes        We need to see        No          Yes         We need to see       No           Yes           We need to see
Income Support, Income-based Jobseekers Allowance, Income-                                             proof of this                                 proof of this                                   proof of this
related Employment and Support Allowance or Pension Credit?

Do they get Disability Living Allowance or Attendance                          No           Yes        We need to see        No          Yes         We need to see       No           Yes           We need to see
Allowance?                                                                                             proof of this                                 proof of this                                   proof of this

It will help us to check their entitlement to the above
benefits if you can provide their National Insurance No.                         Letters    Numbers Numbers Numbers Letters    Letters   Numbers Numbers Numbers Letters   Letters    Numbers Numbers Numbers Letters
Page 10       Part 3                                                About other people who live with you continued                                                                 Page 6

                                                                    First Person continued                     Second Person continued                    Third Person continued

Are they registered blind?                                        No          Yes      We need to see        No          Yes      We need to see        No          Yes      We need to see
                                                                                       proof of this                              proof of this                              proof of this

Are they a full-time student or on a Training Scheme?             No          Yes      We need to see        No          Yes      We need to see        No          Yes      We need to see
                                                                                       proof of this                              proof of this                              proof of this

Do they work?        No       Yes                                 No          Yes      Tell us their gross   No          Yes      Tell us their gross   No          Yes      Tell us their gross
                                                                                       earnings before                            earnings before                            earnings before
If they work, how many hours do they normally                           hrs            deductions                  hrs            deductions                  hrs            deductions
work each week?
                                                                    £                                          £                                          £
                                                                  We need to see proof of earnings           We need to see proof of earnings           We need to see proof of earnings

Do they have any other income?                                    No          Yes      Tell us about it      No          Yes      Tell us about it      No          Yes      Tell us about it
Make sure that you tell us about all other income they have.                           below                                      below                                      below
This includes any benefits or allowances you have not already      If they have more than two other items     If they have more than two other items     If they have more than two other items
                                                                  of income, use part 15                     of income, use part 15                     of income, use part 15
mentioned and dividends or interest from savings.

1. What is this income?

   How much is it before deductions?                                £                                          £                                          £


2. What is this income?

   How much is it before deductions?                                £                                          £                                          £


Is this person currently living or staying away from              No          Yes                            No          Yes                            No          Yes
your home temporarily?
If so, tell us the date they went away and the reason for their
absence.
 About Income Support, Jobseekers Allowance, Employment and                                                                                                              Part 4        Page 11
 Support Allowance and Pension Credit

                                                                     You                                                                  Your partner

Are you or your partner getting Disability Living                  No        Yes         We need to see proof of this                No        Yes         We need to see proof of this
Allowance, Attendance Allowance or Constant
Attendance Allowance?
Are you or your partner getting Income Support,                    No        Yes       If Yes, go to part 11                         No        Yes        If Yes, go to part 11
Income-based Jobseekers Allowance, Income-related
Employment and Support Allowance or Pension
Credit (Guarantee Credit)?
Are you or your partner getting Pension Credit                     No         Yes                                                    No          Yes
(Savings Credit) only, without Guarantee Credit?                   If you are getting Savings Credit, answer the questions           If they getting Savings Credit, answer the questions
                                                                   below then go to part 11.                                         below then go to part 11.

Maintenance (for you/your partner or your children)?               No        Yes       If Yes please provide details in Section 15   No        Yes        If Yes please provide details in Section 15

Do you receive any other government benefits or                     No        Yes       If Yes please provide details in Section 15   No        Yes        If Yes please provide details in Section 15
allowances not already mentioned above?

More questions about income and savings
If you have answered Yes to say that you or your partner are getting Income Support, Income-based Jobseekers Allowance, Income-related Employment and Support Allowance or
Pension Credit (either Guarantee Credit and/or Savings Credit), go to part 11.




                                                                     We must see evidence of your benefits, allowances or pension before we decide how
                                                                     much benefit you can get. Read the checklist with the guidance notes to see what
                                                                     you can use as evidence.
Page 12       Part 5                                             About being self-employed                                                                              Page 6

Are you or your partner self-employed?                           No     Go to part 6   Yes      Answer the questions on this page. You must send us your trading account for the
By “self-employed” we mean working as a sole trader or in a                                     last financial year. If you have only recently set up the business and do not have a
partnership, normally paying Class 2 and 4 National Insurance                                   full year’s accounts, we will need to see some other evidence of your income. We
contributions. We do not mean a director of a limited company.                                  will write to you about this.

                                                                  You                                                       Your partner


What kind of work do you do?


When did the business start?                                                  DD / MM / YYYY                                              DD / MM / YYYY

Do you or your partner work under a business name                No     Yes                                               No        Yes
that is different from your personal name?
If yes, please give the business name.




Do you or your partner have a business address that              No     Yes                                               No        Yes
is different from the address you are claiming for?
If yes, please give details.




How many hours a week do you usually work?


Do you pay into a private pension scheme?                        No     Yes       How much and how often?                 No        Yes         How much and how often?

                                                                  £               every                                     £                   every

                                                                  We must see evidence of your earnings before we can decide how much benefit
                                                                  you can get. Read the checklist in part 19 of the form to see what you can use as
                                                                  evidence.
  About working for an employer                                                                                                                                          Part 6       Page 13

Do you or your partner work for an employer?                          No          Go to part 7
Answer Yes and complete this part if you or your partner are in       Yes         Answer the questions on this page. If you or your partner work for more than one employer, tell us in part 15.
paid employment including if you are currently absent from work
and getting sick pay, adoption pay, maternity or paternity pay. But
do not use this part to tell us about working as a director of a
limited company.
                                                                            You                                                             Your partner


What is the employer’s name and address?




                                                                            Postcode                                                        Postcode


When did you start this job?                                                             DD / MM / YYYY                                                  DD / MM / YYYY


How often do you get paid?                                             weekly         fortnightly      4 weekly      monthly              weekly       fortnightly     4 weekly       monthly


How many hours a week do you usually work?


When will your next pay rise be? (if known)                                              DD / MM / YYYY                                                  DD / MM / YYYY


What is your payroll number?


                                                                            We must see evidence of your earnings before we can decide how much benefit
                                                                            you can get. Read the checklist in part 19 of the form to see what you can use as
                                                                            evidence.
Page 14       Part 6                                              About working for an employer continued                                                    Page 6


                                                                    You                                             Your partner

                                                                  Yes, earnings change with hours worked          Yes, earnings change with hours worked
Do you or your partner’s earnings change according
to how many hours you work every week or month?                   No, earnings are the same every week/month      No, earnings are the same every week/month

Do you or your partner receive any tips, bonuses or               No       Yes       Please give details below.   No       Yes       Please give details below.
other additions?



Do you or your partner pay into a private or company              No       Yes       How much and how often?      No       Yes       How much and how often?
pension scheme?
This includes a scheme run by your employer or a private scheme     £               every                           £               every
that you pay into separately.

Are you or your partner currently receiving any of
the following:
Sick pay (including Statutory Sick Pay or other sick pay from     No       Yes                                    No       Yes
your employer).
Maternity pay (including Statutory Maternity Pay or other         No       Yes                                    No       Yes
maternity pay from your employer).
Paternity pay (including Statutory Paternity Pay or other         No       Yes                                    No       Yes
paternity pay from your employer).
Adoption pay (including Statutory Adoption Pay or other           No       Yes                                    No       Yes
adoption pay from your employer).

                                                                  We must see evidence of your earnings before we can decide how much benefit
                                                                  you can get. Read the checklist in part 19 of the form to see what you can use as
                                                                  evidence.
 About any other work                                                                                                          Part 7        Page 15


                                                      You                                                Your partner

Do you or your partner work as a director of a       No     Yes      We will write to you about this.   No   Yes     We will write to you about this.
limited company?

Do you or your partner hold elected office (for       No     Yes      We will write to you about this.   No   Yes     We will write to you about this.
example, as a local Councillor)?

Do you or your partner do any other paid or unpaid   No     Yes      Please give details below.         No   Yes     Please give details below.
work that you have not already mentioned on this
form?




                                                     We must see evidence of your earnings before we can decide how much benefit
                                                     you can get. Read the checklist in part 19 of the form to see what you can use as
                                                     evidence.
Page 16        Part 8                                     About benefits, pensions and allowances                                            Page 6

Please tick the “Yes” box next to each benefit, credit, pension or allowance that you or your partner are getting or waiting to hear about. Tick the
“No” box for each benefit, credit, pension or allowance that you or your partner are neither getting or waiting to hear about.

                                                            You                                             Your partner

Child Tax Credit                                          No      Yes                                     No      Yes
Working Tax Credit                                        No      Yes                                     No      Yes
Jobseekers Allowance (Contribution-based)                 No      Yes                                     No      Yes
Employment & Support Allowance (Contribution-based)       No      Yes                                     No      Yes
Incapacity Benefit                                         No      Yes                                     No      Yes
State Retirement Pension                                  No      Yes                                     No      Yes
Carers Allowance                                          No      Yes                                     No      Yes
Maternity Allowance                                       No      Yes                                     No      Yes
Bereavement Allowance                                     No      Yes                                     No      Yes
Widowed Parent’s Mother’s Allowance                       No      Yes                                     No      Yes
Widow’s Pension                                           No      Yes                                     No      Yes
Industrial Injuries Benefit                                No      Yes                                     No      Yes
Industrial Death Benefit                                   No      Yes                                     No      Yes
Reduced Earnings Allowance                                No      Yes                                     No      Yes
Retirement Allowance                                      No      Yes                                     No      Yes
Severe Disablement Allowance                              No      Yes                                     No      Yes
War Disablement Pension                                   No      Yes                                     No      Yes
Armed Forces Compensation Scheme Pension                  No      Yes                                     No      Yes

Others (please specify)

Benefits received by other people who provide you or
your partner with care.
Does anyone get or have underlying entitlement to         No      Yes                                     No      Yes
carers allowance for caring for you or your partner?
                                                          We must see proof of all benefits. Read the checklist in part 19 of this form to see
                                                          what you can use as evidence.
  About other money coming in                                                                                                                          Part 9      Page 17

Is there a private pension or work pension that you                  No
or your partner could take now if you wanted to,                     Yes      Tell us the name and
but you have decided to delay drawing?                                        address of the pension
                                                                              provider and, if possible,
                                                                              your policy/membership
                                                                              number.

Do you or your partner have any money coming in                      No       Go to part 10.
(or expect to have some money coming in) that you                    Yes      Answer the questions on this page.
have not already told us about on this form?
Examples of income that you should put in this part:
                                                                     (You do not need to tell us about payments from the Independent Living Fund, the Eileen Trust or the
                                                                     MacFarlane Trust).
Occupational or work pensions, annuities, student grant or loan,
money from a trust fund, state benefits or pensions from another
country, rent from another property that you rent out. Also
include money that is paid directly to someone else on your behalf
(e.g. if someone pays your rent or mortgage for you).

                                                                      Other money 1                            Other money 2                 Other money 3

Name of other income

Who gets it?                                                         You      Your partner                   You      Your partner         You      Your partner


How is the money paid?

How much is it?                                                       £                                       £                             £


How often is it paid?                                                 Every                                   Every                         Every


When did it start?                                                         DD / MM / YYYY                          DD / MM / YYYY                DD / MM / YYYY

When is it likely to go up?                                                DD / MM / YYYY                          DD / MM / YYYY                DD / MM / YYYY

If you or your partner have any other income which you have not yet told us about please provide details on page 27.

                                                                      We must see proof of all income. Read the checklist in part 19 of this form to see
                                                                      what you can use as evidence.
Page 18     Part 10                                           About all bank accounts, savings, investments and property                                Page 6

Do you or your partner have any savings, investments, debts owed to you, land            Yes   Answer the questions in this part
or property in the UK or abroad?                                                         No    Go to part 11

Money in bank, building society and post office accounts etc. This includes current accounts held at a bank, building society or post office. If you and
your partner have more than four accounts, use part 15 to tell us about the others.

                                                                              Type of                                              Account
Account 1: Name of bank etc:
                                                                              account:                                             balance:

Name of account holder:                                                                        Account number:

                                                                              Type of                                              Account
Account 2: Name of bank etc:
                                                                              account:                                             balance:

Name of account holder:                                                                        Account number:

                                                                              Type of                                              Account
Account 3: Name of bank etc:
                                                                              account:                                             balance:

Name of account holder:                                                                        Account number:

                                                                              Type of                                              Account
Account 4: Name of bank etc:
                                                                              account:                                             balance:

Name of account holder:                                                                        Account number:

Do you or your partner have any Premium Bonds?          No
                                                                                £
                                                        Yes        Value:

Do you or your partner have any National Savings        No                      Issue:                       Issue:                      Issue:
Certificates?                                            Yes        Details:
                                                                                Number held:                 Number held:                Number held:

Do you having any savings in cash?                      No
                                                        Yes
                                                              We must see proof of all capital. Read the checklist in part 19 of this form to see
                                                              what you can use as evidence.
 About all bank accounts, savings, investments and property continued                                                                          Part 10     Page 19

                                                           You                                                  Your partner
Do you or your partner have any ISAs, PEPs or TESSAs?    No       Yes     Give the details below:             No      Yes        Give the details below:

 Name/type:                                                Name/type:                                          Name/type:

 Approximate value £                                       Approximate value £                                 Approximate value £

Do you or your partner have any other bonds, gilts or    No       Yes     Give the details below:             No      Yes        Give the details below:
cash savings of any kind?

 Name/type:                                                Name/type:                                          Name/type:

 Approximate value £                                       Approximate value £                                 Approximate value £

Do you or your partner have shares?                      No       Yes     Give the details below:             No      Yes        Give the details below:

 Name/type:                                                Name/type:                                          Name/type:

 Approximate value £                                       Approximate value £                                 Approximate value £

Do you or your partner own any land or property apart from the home you are claiming for?             No       Yes      We will write to you

Do you or your partner’s savings and investments include money that came from any of the following sources? We may have to write to you about this.

Money from the sale of property?                   No      Yes            The vCJD (Creutzfeldt-Jakob Disease) Trust?               No         Yes
An insurance policy?                               No      Yes            Compensation from the Far Eastern Prisoners               No         Yes
An improvement or repair loan?                     No      Yes            of War scheme?
A charitable donation?                             No      Yes            Arrears of the benefits listed below?                      No         Yes
Compensation for a personal injury?                No      Yes            Housing Benefit, Council Tax Benefit, Income Support, Income-based Jobseekers
                                                                          Allowance, Income-related Employment and Support Allowance, Child Tax Credit,
Compensation for atrocities committed by           No      Yes
                                                                          Working Tax Credit, Pension Credit, Disability Living Allowance, Attendance Allowance,
Germany in World War II?
                                                                          Attendance/Mobility Supplement.

                                                              We must see evidence of savings, investments or property before we can decide
                                                              how much benefit you can get. Read the checklist in part 19 of the form to see
                                                              what you can use as evidence.
Page 20        Part 11                                                    About where you live                                                                                             Page 6

Do you or your partner own, or jointly own, the property you are claiming for?                                                                  No       Yes        If yes, go to part 13.
By “own” we mean freehold, or a long lease that was granted for at least 21 years when it started.
Do you or your partner have a shared ownership lease?                                                                                           No       Yes        If yes, go to part 13.
By “shared ownership” we mean that you own a percentage of the equity in your home and your landlord owns the rest.                                                 We will write to you.

Are you or your partner a Council tenant?                                                                                                       No       Yes        If yes, go to part 13.

Are you or your partner a Housing Association tenant or a tenant of a Registered Social Landlord?                                               No       Yes        If yes, go to part 12.

Only answer the remaining questions in this part if you or your partner rent your from a private landlord other than a Housing Association. If you or your partner rent your home from a
Housing Association go to part 12. If you own your home or rent from the Council go to part 13.

Did you ever own your home before you started to rent it?                    No        Yes           If yes, we may write to you about this.

What sort of building do you live in? Tick one box only                   Detached house                                                       Hostel
                                                                          Semi-detached house                                                  Caravan, mobile home or houseboat
                                                                          Terraced house                                                       Board and lodgings
                                                                          Maisonette                                                           Hotel
                                                                          Bungalow                                                             Residential nursing home
                                                                          Flat in a house                                                      Residential care home
                                                                          Flat in a block                                                      Other give details
                                                                          Flat over a shop
                                                                          Bedsit, room or studio flat
Is the property let as:                                                   Furnished               Partly Furnished                        Minimally Furnished                  Unfurnished

Does your home have:                                                      Central heating?                    No         Yes              A garage?                       No         Yes

                                                                          A garden?                           No         Yes              A parking space?                No         Yes

Who is responsible for decorating your home?                              Tenant                  Landlord                      Don’t know

Do you and your household only occupy part of                             No        Yes      If yes, where in the building do you live?         At the front
the building you have ticked?                                                                                                                   In the middle
Room number if known.                                                                                                                           At the back
  About where you live continued                                                                                                Part 11   Page 21


How many floors are there in the property?

Which floor or floors do you live on?
For example, ground floor, first floor, whole house.

How many of the following kinds of room are there in                                            Just for you and your   That you share with other
                                                                        In the whole building
the whole building?                                                                             household               people
(If you live in a flat/bedsit, please answer these questions regarding
your flat/bedsit only).
                                                          Bedrooms

                                                 Bedsitting rooms

                                                       Living rooms

                                                      Dining rooms

                                  Bathrooms or shower rooms

                                                    Separate toilets

                                                             Kitchens

                                                       Other rooms


                                      Describe the other rooms
Page 22        Part 12                                                    About rent                                                                              Page 6

Are you or your partner charged rent for your home?                                              No         If no, go to part 13.
“Rent” includes any payments you have to make to a landlord for permission to live in your home.
                                                                                                 Yes        If yes, answer the questions in this part.
Tick Yes if you would pay rent but you already get Housing Benefit.

How much rent are you charged and how often?                              £                         every

Who is liable for Council Tax at this address?

What is the landlord’s full name and business address?
                                                                          Name
By “landlord” we mean a person or organisation with whom you or
your partner have a tenancy or licence agreement - this is usually the
                                                                          Address
owner of the property.



                                                                          Postcode                                     Telephone

If the landlord uses a managing agent, please provide
                                                                          Name
the managing agent’s full name and business address.
The managing agent is usually the person or company you pay rent
to and contact about things like repairs.                                 Address



                                                                          Postcode                                     Telephone

Are you, your partner or any of you or your partner’s                    No      Yes     Please give details of the relationship:
children related to the landlord or managing agent?
By “related” we mean by blood or by marriage/civil partnership, even                                                      is the landlord’s/agent’s
if the marriage/civil partnership has ended, e.g. father, daughter,
mother-in-law, step-son, grandson, sister, aunt.
Were you or your partner ever the spouse, civil partner                  No      Yes     We will write to you about this.
or cohabiting (live-in) partner of the landlord or
managing agent?
What period does the                                                                                               On what date did you or your
current or most recent   From                DD / MM / YYYY               To        DD / MM / YYYY                 partner’s first tenancy                DD / MM / YYYY
tenancy agreement cover?                                                                                           agreement at this address begin?
  About rent continued                                                                                                                                                  Part 12    Page 23

Is someone else (apart from you and your partner) jointly liable for the rent in your home?                                          No       Yes
By “jointly liable” we mean someone who is a joint tenant or licensee in the agreement that you have with your landlord, even if they do not currently live with you.
Tell us about up to three joint payers below. Use page 27 if there are more than three.
You and your partner’s share of the rent          Share of the rent paid by joint payer 1          Share of the rent paid by joint payer 2            Share of the rent paid by joint payer 3

  £                 per                            £                  per                           £                  per                             £                per

Has the rent been registered as a fair rent by a Rent Officer?                           No        Yes        Please send us the notice of registration form RO5.

Are there any weeks or months of the year when the rent does not                        No        Yes        Please say how many weeks/months.                                Weeks/Months
have to be paid?
Your landlord might call this a “rent-free period”.

Are you or your partner behind with the rent?                                           No        Yes        By how many weeks/months?                                        Weeks/Months

Does the rent include money for any of the following services:
Water charges                                                           No        Yes              Laundry service (for example, clean sheets or towels)                      No       Yes
Fuel (gas/electric) for:                                                                           Cleaning rooms or windows                                                  No       Yes
   Heating                                                              No        Yes              Personal care or support                                                   No       Yes
   Hot water                                                            No        Yes              Subscription TV service                                                    No       Yes
   Cooking                                                              No        Yes              Alarm system                                                               No       Yes
   Lighting                                                             No        Yes              Any other services Please provide details:                                 No       Yes
Meals
   Breakfast only                                                       No        Yes
   Full board (Breakfast, midday meal and evening meal)                 No        Yes
   Part board (Any other meals)                                         No        Yes

                                                                              We must see evidence of your rent and tenancy before we can decide how much
                                                                              benefit you can get. Read the checklist in the guidance notes to see what you can
                                                                              use as evidence.
Page 24     Part 13                                              How your benefit will be paid and the choices you have                                         Page 6

• If you or your partner are a Council tenant, we will pay any Housing Benefit you are awarded into your Council rent account.
• If you or your partner are a Housing Association tenant, you can normally choose whether your Housing Benefit is paid directly to your landlord
  or paid to you.
• If neither you nor your partner are a Housing Association tenant or a Council tenant, we will normally pay your Housing Benefit by transferring
  the money into a bank account that you nominate, unless there is an important reason why we should not do so (supporting evidence may be
  required).
Please use the space below to provide the information we need to decide how to pay your Housing Benefit (supporting evidence may be required).
Tick the relevant box:
     Please pay my Housing Benefit into the bank account nominated below
     This should normally be you and/or your partner’s bank account. If you want us to pay someone else (such as a friend or relative), there is a space in the bank
     account details area below where you can explain why.

     Please pay my Housing Benefit to my landlord because:

           I am a Housing Association tenant/my partner is a Housing Association tenant and I prefer you to pay my benefit to the landlord.

           My partner and I are not Housing Association tenants, but I would prefer you to pay my benefit to the landlord because:




 Bank account details       Name(s) of account holder(s):

If the account holder is someone other than you or your partner, please say why:




Name of Bank/Building Society:                                                                 Sort code:                            _                  _


Account type (e.g. current, deposit):                                                          Account number:
 About living or staying at another address                                                                                                          Part 14   Page 25

Do you or your partner have another home somewhere else                    No        Yes       If yes, do you or your partner pay rent for the other home?
(as well as the one you are claiming for)?
This includes a home in the UK or abroad, even if you do not pay rent      No        Yes       How much?       £                  every
for it.
What is the address of the other home?




                                                                                                                                              Postcode


Are you or your partner staying away from the home you are claiming for?                        Yes     Tell us about it below.

“Staying away” means you are spending nights away from home and not returning                   No      Go to part 15.
during the day time.
Who is staying away from home?                      Just you                    Just your partner          You and your partner
Why are you/your partner staying away from home? Give the reasons in the box below - for example in hospital, visiting relatives, studying.




On what date did the absence begin?                                                   On what date do you/your partner expect
                                                                                      to return home?

                                                                           Please provide the address where you/your partner are staying.




                                                                                                                                              Postcode
Page 26       Part 15                                                  Backdating and any other information                                                    Page 6

We can usually award benefit from the Monday after the day we receive your claim. Sometimes we can pay benefit from an earlier date if you have a good reason for not
claiming earlier.

Depending on your circumstances your claim can be backdated for up to six months.

If you wish us to consider backdating your claim please provide proof of your income and capital for the backdate period and answer the two questions below.

What date would you like your claim backdated to?                 DD / MM / YYYY



  Reasons for delay in claiming (please attach any relevant evidence, for example, letters from doctor, social worker, support worker).




Please note that we need to see evidence of your income and capital during the period you want to claim backdating for.
  Backdating and any other information continued                                                                                                         Part 15     Page 27

                                                        Use the space below to tell us about anything you did not have room to put in the rest of this claim form, or anything
                Other Information
                                                        else you think we should know that we have not asked about.

  Other information continued.




Sports and Leisure Concessions
People entitled to Housing or Council Tax Benefit can use Council       Do you and your partner wish to be registered?
managed sports and leisure centres throughout the East Riding at a
discount one-third of the normal full price for many activities.        No        Yes

Supporting People Services
If you are receiving Supporting People services, the Benefit Section may be able to provide information which could greatly
improve the service that you receive.
Please sign in the box below to authorise the Benefit Section to pass details of the outcome of a Housing Benefit application,
details of a cease to your Housing Benefit entitlement or a change of your address, to the Supporting People Team.
 Page 28       Part 16                                              Backdating and any other information                                                      Page 6

Sharing information with your landlord or managing agent                             Data Protection Act 1998: How we collect and use information
If your Housing Benefit is paid directly to the landlord or managing agent, we        We will use the information you give in this form, and in any supporting
have to tell them some basic information such as the amount of benefit you are        evidence that you send, to process your claim for Housing Benefit and Council
entitled to and when from. If there is an overpayment of benefit to your landlord     Tax Benefit. We may share information with other organisations involved in the
or agent, we have to tell them how it happened. We might also have to contact        administration of benefits, in particular the Department for Work and Pensions,
your landlord to check that the information in this form is accurate, such as the    other local authorities and Her Majesty’s Revenue and Customs; and we may
date when the tenancy began.                                                         obtain information about you from those organisations from time to time in
Other than that, we will not disclose any information to your landlord or            order to process your claim and ensure that your award remains correct.
managing agent without your permission. Sharing information with your landlord       East Riding of Yorkshire Council is under a duty to protect the public funds it
or agent could help us deal with your claim more quickly and reduce the risk of      administers, and to this end may use the information you have provided on this
you falling behind with your rent because of your claim being delayed. If you have   form for the prevention and detection of fraud. It may also share this information
no objection to us sharing information with your landlord or agent in order to       with other bodies responsible for auditing or administering public funds for these
help us deal with your claim more quickly, you can authorise us to do so in the      purposes. For further information, see http://www.eastriding.gov.uk/benefits
space below.                                                                         Where the Data Protection Act allows it, we may:
Sharing information with others                                                      • use the information you have provided for other purposes, such as Council
If there is someone else helping you with your claim (such as a friend, relative,      Tax collection; and
support worker or social worker) and you are happy for them to deal with us on       • disclose the information to third parties for lawful purposes, such as the
your behalf, please provide their name and contact details in the space below.         prevention or detection of crime.
I give my permission for East Riding of Yorkshire Council to share                   East Riding of Yorkshire Council is the data controller for the information on this
information about my Housing Benefit and Council Tax Benefit claim
                                                                                     form for the purposes of the Data Protection Act. Information will be held for
with:
                                                                                     at least three years, and for as long as necessary after that to fulfil the purposes
(Tick any that apply and sign in the bottom box to confirm your permission).
                                                                                     described above.
The landlord                       Yes      No                                       If you want to know more about the information we hold about you or the way
The landlord’s managing agent      Yes      No
                                                                                     we use it, please contact us (see pages 1 and 33 for contact details).

The person named below             Yes                                               Their address:

Their name:

Their connection with you:

Their telephone/email details:

Your signature                                                                                                                         Postcode
  Declarations                                                                                                                                 Part 17    Page 29

Your declaration as the person making the claim                                       Declaration by the person who filled in the form for you
• I am the person claiming Housing Benefit and Council Tax Benefit.                     • I am the person who filled in this claim form on behalf of the person making
• I declare that the information I have given on this form is correct and               the claim.
  complete.                                                                           • I declare that I have as far as possible confirmed with the person making the
• I understand that I must inform East Riding of Yorkshire Council of any               claim that the information given on this form is correct and complete.
  change in my circumstances and/or any change to the information I have               Name:
  provided in this form as soon as a change occurs. I understand I must inform
  East Riding of Yorkshire Council in writing at one of the contact addresses
  provided on pages 1 and 33 of this form.                                             Address:
• I have read the examples at the bottom of this page regarding the changes
  that I must inform the Council about.
• I understand that if I give information that is inaccurate or incomplete, or if I                                               Postcode:
  fail to inform East Riding of Yorkshire Council Benefits Service about a change
  of circumstance, I could be prosecuted.
                                                                                      Signature                                      Date
• I have read and understand the declaration

Signature of person making the claim:            Date                                                                                       DD / MM / YYYY

                                                        DD / MM / YYYY                Changes of circumstances
                                                                                      You must inform East Riding of Yorkshire Council Benefits Service in
Your partner’s declaration                                                            writing immediately if you have a change of circumstance that might
                                                                                      affect your Housing Benefit or Council Tax Benefit. Changes can be
• I am the partner of the person making this claim for Housing Benefit and             reported to the addresses shown on pages 1 and 33 of this form.
   Council Tax Benefit.
                                                                                      Examples of the changes that you must report:
• I have read the information that my partner has given on this form and I
                                                                                      • You, your partner or someone in your household stops getting Jobseekers
   declare that the information is correct and complete.
                                                                                         Allowance, Employment and Support Allowance or Income Support.
• I have read the examples at the bottom of this page regarding the changes           • The earnings, pensions, benefits or other income of anyone in your household
   that my partner must inform the Council about.                                        changes (including your income and your partner’s income.)
• I understand that if I cause or allow my partner to give information that is        • Either you or your partner’s savings or investments change.
   inaccurate or incomplete, or if I cause or allow my partner to fail to inform      • If you, your partner or anyone else moves into your home, moves out or goes
   East Riding of Yorkshire Council about a change in circumstances I could be           to stay temporarily at another address.
   prosecuted.                                                                        • A child in your household leaves school or college.
Signature of partner:                             Date                                • You, your partner or someone in your household starts work.
                                                                                      • Generally, if anything that you have told us about on this form is no longer
                                                        DD / MM / YYYY                   correct.
 Page 30       Part 18                                                 Monitoring our services                                                                           Page 6

Monitoring our services
East Riding of Yorkshire Council works towards eliminating discrimination and promoting equal opportunities. Collecting the following information can help us achieve this.
Data collected will be used to help us to plan and deliver services more effectively to individuals and service users. It will also be used to report on the needs of different
groups of people. Information provided will be treated confidentially in accordance with the Data Protection Act 1998.


National Insurance Number
                                       Letters   Numbers   Numbers    Numbers    Letter


How would you describe your ethnic origin?                                                                                                Are you?
                                                                                                                                                Male
      White: British                                                         Asian or Asian British: Bangladeshi                                Female

      White: Irish                                                           Asian or Asian British: Other Asian

      White: Other White                                                     Black or Black British: Caribbean                            What is your age group?
      Mixed: White and Black Caribbean                                       Black or Black British: African                                    15 or under
                                                                                                                                                16 - 24
      Mixed: White and Black African                                         Black or Black British: Other Black
                                                                                                                                                25 - 59
      Mixed: White and Asian                                                 Chinese                                                            60 and over

      Mixed: Other                                                           Gypsy/Traveller

      Asian or Asian British: Indian                                         Prefer not to say                                            How would you describe your
                                                                                                                                          sexuality?
      Asian or Asian British: Pakistani
                                                                                                                                                Lesbian or Gay
Other ethnic group (please describe)
                                                                                                                                                Heterosexual
                                                                                                                                                Bisexual
                                                                                                                                                Prefer not to say
                                                                                                                                                Other
 Monitoring our services continued                                                                                                                         Part 18       Page 31

Do you consider yourself to be a disabled person?            The Disability Discrimination Act 1995 defines disability as “a physical or mental impairment which has a
                                                             substantial and long-term adverse effect on your ability to carry out normal day-to-day activities”
Yes      No
                                                                   A physical impairment             Mental health issues                   Deaf British Sign Language user
If you have answered yes please tick which of the
following apply (you may tick more than one):                      A visual impairment               A learning difficulty                   Long term condition
                                                                   A hearing impairment              A specific learning difficulty           For example diabetes, multiple
                                                                                                     (For example: dyslexia)                sclerosis, living with HIV or cancer


What is your religion?                              What is your preferred language of communication?

      Christian                                     Spoken                                                              Written
      Buddhist
                                                         English                                                             English
      Hindu
                                                         British Sign Language                                               Other
      Jewish                                                                                                                 Please specify:
                                                         Other
      Muslim                                             Please specify:
      Sikh
      No religion
      Prefer not to say
      Any other religion
      Please describe:



Do you prefer to receive communications in          If yes, please specify which format:
a form or type that is different from standard
written format?                                          Large print                       Easy English                             Text phone/Texbox
                                                         Audio tape                        Braille                                  Type Talk
Yes      No
                                                         Visual (e.g. video)               Compact disc (CD)                        Video Phone
                                                         BSL video                         Computer disc (floppy)                    Other
                                                                                                                                    Please specify:


Thank you for taking the time to provide us with this monitoring information.
Page 32        Part 19                                                    Checklist                                                                                          Page 6

Do not send valuable documents through the post. These can be taken to your local           Evidence of Capital, Savings & Investments
Customer Service Centre where they will be photocopied or scanned and returned to           We need to see proof of any savings, capital or investments that you and your partner
you immediately.                                                                            have.
If you do not have the proofs needed to hand, you should still return this form or you      Below is a list of capital items along with the different types of proof we need to see
may lose benefit. Please provide the proof as soon as possible. If you cannot provide        for each. These proofs must show up-to-date balances and interest:-
the proof needed within one month you must let us know. If you do not let us know
you may not get any benefit.                                                                 •   Bank or building society account - Current statement(s) showing the account
                                                                                                holder’s name, account number and balance. These must also show all transactions
A landlord form and earnings certificate are provided with this form. Additional                 over the last two full calendar months.
earning’s certificates are available from those Council Offices listed on page 33 or can
be downloaded at www.eastriding.gov.uk/benefits                                              •   Internet banking - An original screen print showing the account holder’s name,
                                                                                                account number and balance. These must also show all transactions over the last
                                                                                                two full calendar months.
Evidence of Identity & National Insurance Number
If this is the first time that you have made a claim with us, or you have never been asked   •   Deposit/ISA (cash deposit form) accounts - We need to see the accounts book,
to provide this previously, we need to see proof of National Insurance number and               annual statement (both of which should be updated to include the latest interest
identity for both you and your partner.                                                         payment) or a letter from the bank or building society showing the current balance.
                                                                                            •   Investment Bonds - Statement or letter showing current balance or value of
For you and your partner please provide one original document for National Insurance            investment.
number and one original document for identity from the list below. These must not be
photocopies.                                                                                •   Premium Bonds - We need to see the Premium Bond certificates or a letter
                                                                                                confirming the current investment.
National Insurance Number
• DWP letters                                                                               •   National Savings Certificates - Certificate or letter confirming the number of units
• P45 or P60                                                                                    and the issue number.
• Pay slips                                                                                 •   Stocks and shares - Original share certificate or dividend statement or letter from
• National Insurance Number card                                                                the company, all of which must show the number of shares held and in which
• Former employers pension letter or remittance slip showing National Insurance                 company.
  Number
• Bank statements showing payments annotated with the National Insurance Number             •   Unit Trusts, PEP’s, ISA’s (Investment form) and TESSA’s - The latest valuation
                                                                                                statement showing the amount invested or up to date passbook dependant on
Identity                                                                                        which type of investment has been purchased.
• Current Passport
                                                                                            •   Land or property (but not the home you live in). The Benefit Service will send you
• Driving Licence in photocard format
                                                                                                a separate form to fill in if you have any land or property.
• Recent Gas, Electricity, Water or Telephone bill (not mobile telephone) paid in yours
   or your partner’s name                                                                   Evidence of Earnings
• Bank statement (for current address)
                                                                                            We need to see the following as proof of earnings for you and your partner:-
• Birth Certificate
• Letters from Government department (e.g. DWP, Home Office)                                 • Last 2 consecutive pay slips (if you are paid monthly or 4 weekly) or the last 3
• European Member State Identity Card                                                           consecutive pay slips (if you are paid fortnightly) or the last 5 consecutive pay slips
• Marriage Certificate                                                                           (if you are paid weekly).
• Divorce or Annulment papers                                                               • Completed Earnings Certificate (this must have a company stamp or be
• Medical Card                                                                                  accompanied with a letter on company headed paper).
• Life assurance or insurance policies                                                      If you have just started work and cannot provide all of the payslips that we require,
• Letter from a Solicitor, Social Worker or Probation Officer                                please supply those that you currently have. We will require all of them as you
• Certificate of Employment in HM Forces or Merchant Navy                                    receive them but may be able to calculate your benefit based on the payslips that you
                                                                                            currently have.
    Checklist continued                                                                                                                                               Part 19       Page 33

Evidence of other income                                                                         Evidence of rent
We need to see proof of any other money that you and your partner have coming in. The            You do not need to provide proof if you rent your home from the Council. If you rent your
type of proof we need includes:-                                                                 home from a Housing Association or private landlord we need to see one of the following:-
•    Bank statements showing the last 2 payments of an income.                                   •   Your tenancy agreement.
•    For students we require documents from the Student Loans Company showing the                •   A completed landlord form (available from the Benefits Service or Customer Service
     financial assessment and term times.                                                             Centre). This must be signed by both the landlord and the tenant.
•    Child Support Agency letter if paid into the bank.                                          •   Your rent book or rent receipts.
•    Maintenance: we do not need to know about any maintenance that you receive for your
     children. However if you receive maintenance for any other reason we need to see            Evidence of money paid out
     proof of this. This proof may include a letter from the person or organisation paying the   We need to see proof of any money that you and your partner pay out towards pensions,
     maintenance or a bank statement showing payments being made.                                childcare or a parental contribution to a student grant. This list below shows which proofs
•    Rental income from other properties.                                                        we need to see.
Evidence of benefits, pensions, tax credits & allowances                                          •   Pension policy letters or payslips that show the amount being paid into a pension
                                                                                                     scheme.
We need to see proof of any benefits and pensions that you and your partner get. We need
to see one of the following for each type of income:-                                            •   Your last 2 months bank statements if the pension is paid from a bank account.
• All pages of your latest benefit, pension or tax credit award letter.                           •   Invoice from registered childcare provider or a letter outlining the payments, both of
                                                                                                     which must show the Ofsted reference number of the childcare provider.
• Bank statement(s) showing the last 2 payments if paid into bank.
                                                                                                 •   Student award notice.
• For a former employers or private pension we require a recent letter outlining the
    amount paid or a recent remittance slip.

    Contact addresses and further advice

Telephone: (01482) 394799 Email: benefit.assessments@eastriding.gov.uk                            Complaints, comments or compliments
Website: www.eastriding.gov.uk/benefits
You can also contact us in person or by post at any one of the offices below:                     East Riding of Yorkshire Council is committed to providing a high quality service to all of
Anlaby                  17 Hull Road                                                             our customers. We welcome feedback from customers and if you would like to submit a
Beverley                Cross Street                                                             complaint, comment or compliment, further information can be obtained by contacting us
Bridlington             Town Hall, Quay Road                                                     using the details shown on this page.
Brough                  Petuaria Centre, Centurion Way
                                                                                                 Anyone claiming Housing or Council Tax Benefit from East Riding of Yorkshire Council can
Cottingham              Civic Hall, Market Green
Driffield                Council Offices, West Garth                                               get independent advice on claiming benefits or making an appeal. A list of advice agencies
Goole                   Council Offices, Church Street                                            can be obtained by contacting us using the details shown on this page.
Hedon                   2 New Road
                                                                                                 This is a Housing Benefit and Council Tax Benefit claim form. East Riding of Yorkshire
Hessle                  Peeler House, Ferriby Road
                                                                                                 Council will, on request, provide this document in Braille, LARGE PRINT or an audio
Hornsea                 75 Newbegin
                                                                                                 version or, if English is not your first language and you need a translation, we can get one for
Howden                  69 Hailgate
                                                                                                 you.
Market Weighton         The Wicstun Centre, 14 Beverley Road
Pocklington             Burnby Hall
Withernsea              243 Queen Street
✁
                                                               PLEASE RETURN THE COMPLETED CERTIFICATE TO:
                                                               The Benefit Section, East Riding of Yorkshire Council, PO Box 12, County Hall, Cross Street, Beverley,
                                                               East Riding of Yorkshire HU17 9BD
                                                               Telephone: (01482) 394799

CERTIFICATE OF EARNED INCOME                                                           PRIVATE AND CONFIDENTIAL

To be completed by employee
Name                                                                                      Occupation



Address
                                                                                          Signature                                   Date

                                                                                                                                                    /            /


                                                                                          Claim Reference Number ( If known )




To be completed by employer                                                               Please indicate ( ✓ ) the method of payment

I would be grateful if you could assist your employee by confirming the details                Cash                    Cheque                    Direct into bank account
above, providing the information requested below and returning it to the address at
the top of this form

Please provide the National Insurance number for the employee                             Please indicate the normal basic wage and normal hours worked by the employee
Letters   Numbers Numbers Numbers Letter
                                                                                           £                      Normal basic wage                                  Normal hours


Please provide the Tax Code for the employee                                              Please indicate how ( ✓ ) often the employee is paid

                                                                                               Weekly              Fortnightly          4 Weekly             Calendar Monthly

Please indicate ( ✓ ) if this job is a Government funded training scheme?                 Please provide the date of the most recent pay increase for the employee

    Yes         No                                                                                      /          /

If Yes, please state the name of the scheme                                               Please provide the date that the employee started working

                                                                                                        /          /
                                                                                                                                                                                                      ✁
Gross pay for the last 5 weekly, 3 fortnightly, or 2 monthly/4 weekly period
                                 ,
(including overtime, bonus, SSP SMP etc.)

                                                                               Working Families
   Pay       Number of                                        ,
                                                          SSP SMP                Tax Credit or                                                           Superannuation
  Period       Hours                                  included in Gross            Disabled                Tax Paid            National Insurance          or Pension
                                 Gross Pay                                                                                                                                             Net Pay
  Ending      Worked                                         Pay              Persons Tax Credit         by Employee             Contributions            Contribution
                                                                                   Included


   Date        Hours           Pay         Year        Pay         Year        Pay          Year        Pay         Year        Pay          Year        Pay         Year        Pay           Year
                               this         to         this         to         this          to         this         to         this          to         this         to         this           to
                              Period       Date       Period       Date       Period        Date       Period       Date       Period        Date       Period       Date       Period         Date

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


Name
                                                                                                   I confirm that the information given is true and complete

Business Name                                                                                      Signature                                        Date

                                                                                                                                                                     /             /

                                                                                                   Position in Firm



Business Address                                                                                   Company Stamp
                                                                                                                                                        If you do not have a company stamp,
                                                                                                                                                        please attach a company letterhead
                                                                                                                                                        signed by the employer




Business Telephone Number



 East Riding of Yorkshire Council will, on request, provide this document in braille or large print.
 If English is not your first language and you would like a translation of this document, please telephone 01482 393939.
✁
                                                                    PLEASE RETURN THE COMPLETED CERTIFICATE TO:
                                                                    The Benefit Section, East Riding of Yorkshire Council, PO Box 12, County Hall, Cross Street, Beverley,
                                                                    East Riding of Yorkshire HU17 9BD
                                                                    Telephone: (01482) 394799

    LANDLORD FORM                                                                                  PRIVATE AND CONFIDENTIAL

    To be completed by benefit claimant                                                            I understand the following:
    If you do not have a tenancy agreement or license to occupy your home,                         •   If I give information that is incorrect or incomplete, you may take action
    please ask your landlord, or your landlord’s managing agent to fill in this                        against me.
    form.
                                                                                                   •   I know I must let the council know about any changes in my circumstances,
     Name                                                                                              which might affect my claim.

     Address                                                                                       •   I declare the information given on this form is correct and complete.


                                                                                                   Signature of person claiming                            Date

     Post Code                                                                                                                                                    /       /


    To be completed by landlord or managing agent                                                  Do you have a managing agent who collects the rent?
    Please fill in this form for your tenant. Their benefit claim cannot be worked
    out until we get this information.                                                             Answer Yes or No

    Please answer all of the questions.                                                            If Yes what is the name and address of the managing agent?
    Please write in BLOCK CAPITALS, using BLACK INK.
    Landlord’s Name and Address                                                                    Managing Agent’s Name and Address




     East Riding of Yorkshire Council will, on request, provide this document in Braille or large print.
     If English is not your first language and you would like a translation of this document, please telephone 01482 393939.
                                                                                                                                                                               ✁
When did they move into your property?                                       How often do they have to pay you rent?
(Please give date)



                                                                             Does their rent include money for service charges?
When did their tenancy start?
                                                                             Answer Yes or No
(Please give date)

                                                                             If Yes, please list all the service charges included in their rent.

                                                                             What services are included in their rent?                     How much is charged?
When did they start paying rent to you?
                                                                                                                                             £
(Please give date)
                                                                                                                                             £

                                                                                                                                             £
Do you require them to give notice before leaving the property?
                                                                                                                                             £
Answer Yes or No
                                                                                                                                             £
If Yes, what period of notice do they have to give?                                                                                          £

                                                                             Are they in arrears with their rent?
How much rent do you charge them?               £
                                                                             Answer Yes or No

                                                                             If Yes, how many weeks are they in arrears?

The information given on this form is true and complete.                     The Data Protection Act
                                                                             The information collected on this form, and from any supporting evidence by the East Riding of
I understand that if I give information on this form that is incorrect you   Yorkshire Council will be used for Council Tax and benefit purposes. The information may be
may take action against me.                                                  passed to other council and government departments as permitted by law.
                                                                             We may check information provided by you, or about you provided by a third party, with other
Landlord/Managing Agents Signature                                           information held by us. We may also get, or give information to third parties to prevent or
                                                                             detect crime, or to protect public funds in other ways as permitted by law. These third parties
                                                                             include Government Departments and local authorities.
Date                                                                         The East Riding of Yorkshire Council is a Data Controller for the purpose of the Data
                                                                             Protection Act 1998.

				
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