YOU

YOUR PARTNER

Postcode Postcode

N;~, Isall Council Walsall Council

Revenues and Benefits Service

Civic Centre, Darwall Street Walsall WS1 1XU

Telephone: 0845 111 2855

E-mail: BenefitsService@Walsall.gov.uk

First contact date Phone / Letter / Visit

Signature

Office use only

I wish to claim for: (please tick)

Second adult rebate Free school meals

Housing benefit Council tax benefit

Housing Benefit and Council Tax Benefit Change in Income Form This form is to be completed if you have had a change in your income. It is to be completed by people who have recently stopped or are about to stop receiving Income Support Income based Job Seekers Allowance or Pension Credit (guaranteed credit)

Part 1 About you and your partner

Please answer YES or NO

If you do not have a National Insurance Number, or cannot find it, tick this box.

Do you have a partner who normally lives with you? (By partner we mean someone you are married to or with whom you are in a civil partnership, or someone you live with as if they are your husband, wife or civil partner).

Last Name

Other Names

Any other last names you have used

Title (Mr, Mrs, Ms etc.)

Address You don't need to tell us your partner's address if it is the same as yours.

Date of Birth

National Insurance Number (You can find this on payslips or letters from The Department for Works and Pensions or the Tax Office. We cannot decide your claim if we do not have your National Insurance Number).

Daytime Telephone Number

E-mail Address

If you have a partner, you must answer all the questions about them, as well as yourself.

f you do not have a National nsurance Number, or cannot

find it, tick this box.

Part 1 Abe-:wt y 7j and 7r,1~7[` partner continued

YOU

YOUR PArITNER

PLEASE ANSWER YES OR NO

Do you or your partner get Disability Living Allowance?

If YES How much?

Do you or your partner get Attendance Allowance?

If YES How much?

Does anyone get Carer's Allowance for looking after you or your partner?

Have you or your partner ever been told that you are entitled to Carer's Allowance even if you do not receive it, because you are getting another benefit instead?

Care £ Care £

Mobility £ Mobility £

£

Are you or your partner:

Registered blind

Long-term sick or disabled (i.e. 52 weeks or more).

Have you regained your eyesight within the last 28 weeks?

Have you got an invalid carriage/adapted vehicle/ motability scheme vehicle?

2

If NO Go to Part 3

If NO Go to Part 4

,Part 1 About you and your partner continued

YOUR PARTNER YOU

Are you or your partner:

A full time student

A student nurse

A paid carer

An apprentice

On youth training

In legal custody

Severely mentally impaired

Do you or your partner pay towards the loan/grant of a student in further or higher education?

If YES How much? £ per £ per

Part 2 At( P ": v^il''Tj

Are there any children in your household?

How many children live with you?

Part 3 AFx; 7,, ~) I c-' , WIv( Fi"e VLV ''I" -O u

Do any adults usually live with you and your partner?

How many adults live with you?

3

Part 4 Air +ut being ~ U - I e

Are you or your partner self-employed?

If NO, go to part 5 : If YES, please continue. Please send us your accounts for the last financial year. If you have only recently set up the business and do not have a full year's accounts, we will need to see some other evidence of your income and expenditure. We will write to you about this.

YOU

YOUR PARTNER What kind of work do you do?

When did the business start?

What is the business address?

Postcode Postcode

Are there any other partners in the business?

If YES How many? Tell us their name(s) and address(es).

How many hours a week do you usually work?

Do you pay into a private pension scheme?

If YES How much?

How often?

f E

every every

We need to see proof of these payments.

We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist at part 15 to see what you can use as evidence.

4

You

YOUR PARTNER

PL

every every

C

Part 5 F-F I, -iut v° P _ rking for an em -Moyer

Do you or your partner work for an employer?

If YES, how many jobs do you have? (If you have more than one job, we will write to you about your other jobs).

What is your main employer's name and address?

Postcode Postcode

When did you start this job?

What is your payroll, employee, or staff number?

Are you employed for a limited period?

If YES When will you finish?

How often do you get paid?

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

How are you paid? (e.g. in cash, by cheque or straight into bank or building society account).

When was your last pay rise?

When will your next pay rise be?

5

When did it start? When did it start?

When did it start? When did it start?

JE

per F

per

When did it start?

we must see evidence of these payments

When did it start?

we must see evidence of these payments

Part 5 Ab(_) ut w V ing for an employer continued

YOU YOUR PARTNER

How many hours a week do you usually work?

Give details of any regular overtime, bonuses or commission.

Are you getting Working Tax Credit with your earnings?

Are you getting Statutory Sick Pay or Statutory Maternity Pay / Paternity Pay from your employer?

Are you getting any other Sick Pay or Maternity Pay / Paternity Pay from your employer?

Do you pay into a private or company pension scheme?

If YES How much?

Do you or your partner do any other work? (This could be voluntary work or any other work, even if it is not paid work).

We must see evidence of your earnings before we can decide how much benefit you can get. Read the checklist at part 15 to see what you can use as evidence.

If you cannot supply evidence of your/your partner's earnings, Walsall Council will contact your/your partners employers directly.

Do you agree to Walsall Council contacting your/ your partner's employer's for evidence of earnings?

6

,Part 6 A 7 i Ibenc- -Fts, [-) ,(-!nsions anid tax credits

YOU YOUR PARTNER

Do you or your partner get any state benefits, pensions or tax credits?

Have you applied for a state benefit, pension or tax credit, but have not yet received it?

If YES what is it?

When did you apply?

Please tell us if you receive any of the following:

YOU YOUR PARTNER HOW OFTEN IS

IT PAID?

HOW IS IT PAID? e.g. building society, bank

etc.

Child Benefit £ £

Child Tax Credit £ £

Working Tax Credit £ £

Job Seekers Allowance (Contribution Based)

£ £

Retirement Pension £ £

Pension Savings Credit £ £

Widows Pension/ Bereavement Allowance

£ £

Widowed Mother's/ Parent's Allowance

£ £

Statutory Sick Pay £ £

Statutory Maternity Pay/ Paternity Pay/ Maternity Allowance £ £

Incapacity Benefit £ £

Severe Disablement Allowance

£ £

Industrial Disablement/ Death Benefit

£ £

Carer's Allowance £ £

Attendance Allowance £ £

Disability Living Allowance (Care)

£ £

Disability Living Allowance (Mobility)

£ £

War Disablement/ War Widow's Pension

£ £

Any other Benefit or Pension, if so what?

£ £

7

Part 6 About r _.nefita, "s and tax cred!ts continued

Is any money being taken off your or your partner's state benefits or pensions to pay back a loan or overpayment to the Department for Work and Pensions or for any other reason?

If YES, from which benefit?

£ £ How much is being deducted?

What is the deduction for?

Do you or your partner receive a personal pension, former employers pension, occupational pension or annuity?

If YES, how many do

you have? (If you have more than two we

will send you a separate page).

How much is the pension? £ per £ per

How much is the pension? per per

Have you or your partner chosen to postpone / defer taking an income from an annuity? IF YES, we will write to you.

We must see evidence of any state benefits/pensions or tax credits before we can decide how much benefit you can get. Read the checklist at part 15 to see what you can use as evidence.

8

YOU

YOUR PARTNER

M

F

per per

C

per per

Address:

JE per

Address:

f per

Full-time? Part-time? Full-time? Part-time?

f f

Part 7 o- :T j, (_ r w -),L J 7,7,r c(13 n T 7 Tu 77

Do you or your partner, or any children you are claiming for, have any money coming in that you have not already told us about on this form?

(This includes, for example, maintenance, child support, training allowances, If NO Go to Part g

payments from property that you rent out or money from a trust fund. If YES

Also tell us about any money you get from people living in your house as Answer the following

boarders, lodgers or subtenants). questions.

Do you or your partner receive maintenance or child support for yourself or your children?

If YES, Please state how much it is and how often it is paid?

Who is the maintenance / child support for?

Are you or your partner on a training scheme?

If YES, tell us the name of the scheme?

How much and how often are you paid?

Does anyone pay you or your partner for rooms or property that you rent to them?

If YES, please provide details of the property and the money you or your partnerreceive.

Are you or your partner a student?

Do you study: (Please tick)

How much is your student loan/grant?

We must see evidenc you can get. Read the

income before we can decide how much benefit 44i N st at part 15 to see what you can use as evidence.

9

MMM

Part 8 About savV (-,, anW(LL'_ I ►:

Do you or your partner have any Post-Office, Building Society or Bank accounts in the UK or abroad? .

7 Ab,:2-)rt other money comij-j(-;, !n continued

YOUR PARTNER YOU

Do you or your partner receive any other income?

If YES, please tell us the type of income?

How much is received and how often?

' Sri:,%, er all the questions in this part. We must see evidence of all the savings, property and/or land.

Read the checklist at Part 15 to see what you can send as evidence.

If YES, Please tell us how many accounts you have? Please tell us about all of your accounts, even empty or overdrawn ones.

Name of bank/ building society etc.

Name of account Account number Balance

Please tell us about any other accounts you have on a separate page.

Do you or your partner have any other savings and/or land in the UK or abroad? This includes cash, accounts, Credit Union, Premium Bonds, National Savings Certificates, stocks and shares

If yes, please give details on the next page.

10

JE

per f

per

Issue number

How many

Part 8 Abf, ),Li ~J jP e3[)erty a L rrdr c land continued

YOU YOUR PARTNER

Do you or your partner have any premium bonds?

If YES, please tell use the value?

Do you or your partner have any National Savings Certificates?

If YES, please tell us?

Issue number

How many

Do you or your partner have any stocks, shares, bonds or unit trusts?

IFYES,

Type How many? Type How many?

Stocks Stocks

Shares Shares

U nit Trusts Unit Trusts

Type Current value? Type Current value?

Bonds Bonds

Tessas Tessas

I SAs I SAs

Any other Any other

11

YOU

YOUR PARTNER

Address

Postcode

Part 8 About saviti pri 3er~" y and/or land continued

Do you, or your partner own or partly own any property, land or timeshare, other than the home you live in, either in the UK or abroad? Answer 'YES' even if you have a mortgage or loan for the property, land or timeshare.

Please tell us the address. We will send you a form about this.

Part 9 Anything else V' ))A rr~ red to telFj ~ - s

Use the box below to tell us anything else that you think we should know about, such as people moving in or out of your home, changes in your rent or any other changes in your circumstances since your last claim.

If you are sending separate sheets of paper with this form, tell us how many?

F i t '[ l Pad-ong -nefit

Housing benefit is paid by crossed cheque. If you decide to have this cheque paid to yourself you will have to pay it into your bank or building society account.

Please tell us who you want your benefit paid to:

Yo u Your Landlord

Your Landlord's agent

Shah,h -P- ~i inf(_),LTn! Sharing information with your landlord, where you have asked us to pay your housing benefit direct to them, may help us deal with your claim more quickly. It may also reduce the risk of you falling behind with your rent because of your claim being delayed.

We may need to confirm information with your landlord before we can make a decision on your claim, for example the start date of your tenancy, or the amount of your rent. In these circumstances we can contact your landlord without your permission.

Under the Data Protection Act 1998 we need your permission to discuss anything else.

12

Part 11 BacL'dafLi j

We are sorry but we cannot backdate free school meals.

We can usually award housing benefit and/or council tax benefit from the Monday after we receive your claim. Sometimes we can pay benefit from an earlier date if you have a good reason for not claiming earlier. If you want us to consider paying your benefit from an earlier date, tell us when you want benefit from and why you did not claim earlier.

Date you want to claim benefit from:

Tell us why you have not claimed earlier. You need to give us as much information as possible, including details of your income for this earlier period. Please use a separate sheet if necessary.

Part 12 111-d cr4 ~L) Its, .,~i n To be completed if someone has filled in this form for you.

I have confirmed with the person claiming that the ans have written on this form are correct.

Name of the person who filled in the form:

Signature of the person:

Relationship to the person claiming:

Date:

13

Part 13 Deciaraf,)In

Please sign this declaration.

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

This is my/our claim for housing benefit and/or council tax benefit and/or free school meals. I/We declare that the information I/We have given on this form is correct and complete to the best of my/our knowledge.

I/We authorise the council to make any necessary enquiries to verify the information on this claim.

I/We authorise the council to cross check the information I/we have given with other parts of the council, the Rent Service, other authorities and agencies.

I/We understand that if I/we give information that is incorrect or incomplete or fail to report any changes which might affect my/our benefits I/we may be prosecuted.

/We understand that I/we must always tell you about any changes in my/our circumstances.

/We understand that if I/we do not tell you about any changes of circumstances and you pay too much benefit because of this, I/we may have to pay it back.

/We understand that I/we may be prosecuted if I/we do not tell you about any changes of circumstances.

Date Claimant's Signature

Partner's Signature

Part 14 Data Prp'6'.~~ jtion

Date

The information given on this form will be held on computer. It will be subject to the provisions of the Data Protection Act 1984 (as amended by the 1998 Data Protection Act). The information you have given is confidential.

We may supply certain information to third parties for use in determining your claim and/or for the purpos-es of data matching for the prevention and detection of fraud.

We may use certain information on this form to assess your entitlement to a discretionary housing payment. We may also use certain information to inform and advise you about other welfare benefits.

Receipt issued by:

Date

14

Pant 15 Checklist A

Please tick to tell us what evidence you are sending with this form. We must see original documents, not copies. Please do not send valuable items through the post. If you can bring them into our office, we will photocopy the details we need and give you the documents back straight away. If you cannot get into the office, phone us for more advice. If you are a Housing Association tenant your Housing Association may be able to help you complete your form and photocopy your documents.

If you cannot provide the evidence we need at the moment, send the form back to us now and send the evidence later. We can start to process your claim, but we will not be able to pay you any benefit until we have all the evidence. Please tell us if you are having problems getting this evidence.

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

Evidence of identity Such as a birth certificate, marriage certificate, passport, medical card, driving licence, UK residence permit, EEA identity card or recent gas or electricity bill. We need to see two of these documents for you, and your partner if you have one.

Evidence of National Insurance Number Such as National Insurance Number card, payslips or letters from the Department for Work and Pensions or the tax office.

Evidence of savings and property and/or land Such as all your bank, building society or Post Office books, full bank statements and certificates for Premium Bonds, National Savings Certificates, ISAs, stocks, shares, and unit trusts. The evidence you send must show details for at least the last 2 months.

Evidence of earnings This means your last 5 payslips if you are paid every week, your last 3 payslips if you are paid every 2 weeks, or your last 2 payslips if you are paid every month. We may contact your employer if you do not have these payslips. If you or your partner are self- employed, we need to see your accounts for the last financial year or, if you have been trading for less than 6 months, a summary of your trading records so far.

Evidence of other income Such as a pension slip from a former employer or a letter from the court showing how much maintenance you are getting. We need to see evidence of any money people pay you for rent.

Evidence of benefits, allowances or pensions Such as your Giro's, or notices or letters from the Department for Work and Pensions confirming how much you get. If you do not have evidence, let us know straight away. Please do not send any DWP payments through the post.

Evidence of rent and tenancy Such as a rent book, rent receipts, a tenancy agreement or a letter from your landlord.

Evidence of money paid out Such as letters about your contribution to a student grant/loan or maintenance, agreements or receipts from registered childminders.

15

Documents seen:

1

2

3

4

5

Date seen:

Name:

Signature:

PLEASE RETURN THE CLAIM FORM IMMEDIATELY, EVEN IF YOU DO NOT HAVE ALL THE EVIDENCETO SUPPORTYOUR CLAIM. ANY DELAY COULD COSTYOU MONEY.

If you need to see us but are unable to call in because of serious ill health or a disability, we can arrange to see you in your home. If you need to provide documents in support of your claim but cannot call in yourself, we will accept your documents from a relative or friend. However, due to customer confidentiality, we will not discuss any details of your claim with another person without your written permission. We will give you a receipt for any documents we have copied. If you need us to arrange an interpreter, we will try to do this within 3 working days. If you need an appointment or home visit, we will try to arrange this within 14 days of the request. If you have any ideas how we can further improve our service we will be pleased to hear from you.

YOU U~_Ad 0 UGLALIA 1!I~ Ly/:

Telephone: 0845 111 2855 E-mail on: BenefitsService@walsall.gov.uk Post: Revenues and Benefits Service, Civic Centre, Darwall Street, Walsall, West Midlands WS1 1XU Fax: 01922 635258

Irl Please write your name and address below.

Name:

Address:

Postcode:

Walsall Council Revenues and Benefits Service Darwall Street Walsall WS1 1XU Telephone: 0845 111 2855

34492 JL 08/07