page 1 - start page - microsoft... · submitting the form: when the form has been completed and you...

- Start Page

Form FilenameTitle Customer Name

DOB NINO

TEL

Data Validation Ref

Email

Notes

Customer Address

Date Form Started

Date of E-signing

Date Submitted

Occupancy typeAdvisor Name (who started form)

Advisor Department

Form Reference

HB and CT Scheme Application Form (1.0) PB 08/06/2018

V1

For Official Use Only

RC: RS: MC:Claim Num / Ref

CTax Num / Ref

Submitting the form: When the form has been completed and you have checked that it is free of errors, pressing theSubmit button will send the data over the internet to the Benefits department, so that we can begin processing your formimmediately.

- Help Information

You can move back and forth through pages by using the Next and Back buttons on the menu.

Please read these guidance notes before completing your application form.

Housing Benefit can pay all or part of your rent. Council Tax Support can pay all or part of your Council Tax. It cannot helpwith water charges, fuel charges, meal charges or mortgage payments. The amount you receive depends on yourpersonal and financial circumstances. If you, or your partner, have combined savings of £16000, you cannot get Housing benefit or Council Tax Support (unlessyou receive Pension Guarantee Credit).

This form uses the latest internet technology to make it quick and easy for you to complete and submit an onlineapplication. The form will help and guide you through your application and make sure it is filled in correctly. Once openedon the internet, you can fill in and save the form off-line. Reconnection to the internet is only required when submitting thecompleted form.

How to use this online form

About Housing Benefit and Council Tax Support

For further help in using this form click on the Help info button on the control panel on the left.

Providing documents and information with your claimWe will need to see proof of some of the things you write about on the form. When you have completed the form, it will tellyou what documents we need to see (original documents please). In some situations we may need to ask you for additional information and proof. We do not advise you to send valuable items such as bank books or passports in the post. We have an enquiry counter atthe Civic Office where you can bring them. Opening Hours: 8.30am to 5.00pm Monday to Friday. You can, if you prefer, send your proof through the post to Doncaster Council, Benefits Section, Civic Office, Waterdale,Doncaster, DN1 3BU. They will be returned to you as soon as they have been processed. We cannot pay you benefit until we have seen the proof we need. If you do not have all the evidence you need, submit theform anyway as Housing Benefit / Council Tax Support is normally granted from the Monday following the date you submitthe form. You will then be given one calendar month to provide the evidence.

What is the Council's Local Council Tax Support Scheme?If you have a low income, you may be entitled to some help with your Council Tax. The Council's Local Council TaxSupport Scheme can pay all or part of your Council Tax. The amount of help you get generally depends on your incomeand savings and the income and savings of anyone else who lives in your home.

Second Adult Rebate Can only be claimed by people who have reached Pension Credit age. If you have someone over 18 sharing your home, you may be able to claim a rebate for them if they satisfy all of the

If you are entitled to both Second Adult Rebate and Council Tax Support, we will compare the two amounts of benefit andpay you the higher amount. We will tell you when this happens. You cannot get both benefits at the same time. If you are entitled to Second adult Rebate you should only fill in Parts 1, 3, 14 and 16 and complete the declaration

• • • •

They do not pay you rent They are not your husband, wife or partner They do not have to pay Council Tax They have a low income

From 11 October 2017 you can only claim Housing Benefit if: •You or your partner are the qualifying age for Pension Credit, or •You have three children or more who live with you, or •You are living in supported/exempt accommodation, (your home is exempt if it is provided by a Housing Association or Not for profit landlord and includes care, support orsupervision). •You are living in temporary accommodation (your home counts as temporary accommodation if it has been made available to you by the local authority or a registeredhousing association as a result of you being homeless or to prevent you becoming homeless) If none of the above apply to you, you should claim Universal Credit for help towards your rent. If you need to claim Universal Credit for help towards your rent, please visit www.Gov.uk

Universal Credit

- Help Information - continued

We will use the information you give in this form, and any supporting evidence you send, to process your claim for HousingBenefit and Council Tax Support. The information that you supply will be used to populate your single customer record which will provide an overview of theservices you receive from the Council and will help us to provide a better service to you. We will use the information to recover debts, and to prevent, detect and prosecute fraud and we may share some or all of theinformation with external bodies responsible for the administration of public funds. We may share the information with othercouncil services to assess your eligibility for services and to identify and advise you about other services you might beinterested in. We may match the information you provide with other information we hold about you whether provided by us, by you or byanyone else. We may also obtain other information about you from other parties and give information to them to:

How we collect and use information

You must tell us immediately, by telephone or in writing, if your circumstances change

• • • •

Make sure the information is accurate Prevent, detect and prosecute fraud Protect public funds, and Recover debts owed to the Local Authority

These third parties include government departments, other local authorities and private sector organisations such as banksand organisations that lend you money, credit reference agencies and your landlord. We will only process and share your information as set out here and at times in accordance with the Data Protection Act1998. These principles include keeping your information secure and up to date and using it in a fair and lawful way forspecified purposes. The council is the Data Controller under the Data protection Act 1998. Please contact us if you would like to know more about the information we hold about you and how we use it.

The amount of Housing Benefit, Council Tax Support or Second Adult Rebate you will get will be based on the informationyou provide on the form. If any of your circumstances change, you must let us know within one calendar month of the change. You can also reportchanges using the Change of Circumstances form on our website or by calling us on 01302 735336. You may be asked toprovide documentary proof of any change that you report. Examples of change are as follows:

• • • • • • • • • • • • •

If you stop receiving Employment and Support Allowance (income related), Income Support or JobseekersAllowance (income based) You or your partners state benefits change You, or your partner, start work, change jobs or have a wage increase or reduction The amount of private/company pension you, or your partner, receive goes up or down The amount of saving or investments you, or your partner, have changes The amount of Working Tax Credit or Child Tax Credit you, Or your partner, receive goes up or down If you , or your partner, start to receive another type of income or benefit The rent you are charged changes (if your landlord is NOT St Leger Homes) A child leaves school and child benefit ends for them Someone moves in or out of your home If you, or your partner, move home If anyone in your household goes into hospital, residential care, legal custody or goes abroad Any changes in non-dependants’ income

If you don't tell us within one calendar month and the change would increase you benefit, you will only receive the increasedamount from the Monday following the date we received your notice. If you are late telling us about a change please givereasons why you did not tell us on time as we may be able to look at our decision again. If the change results in a reduction in your benefits, this will apply from the Monday following the date the change happenedand you will have to pay any overpaid benefit.

- Main form

Do you have three or more dependant children who livewith you?

No Yes

Are you above state pension age? No Yes

You must answer all of these questions before continuing with the application form.

Universal Credit Filter Questions

If you are not sure, please visit the website www.gov.uk

Do you live in supported accommodation? No Yes

The introduction of Universal Credit has started in the Doncaster area. To ensure you are claiming the correct benefit you must answer the questions below to check whether you should claimUniversal Credit and Council Tax Reduction or Housing Benefit and Council Tax Reduction.

Your home is exempt if it is provided by a HousingAssociation or not for profit landlord and includes care,support or supervision.

Do you live in temporary accommodation? Your home counts as temporary accommodation if it hasbeen made available to you by the local authority or aregistered housing association as a result of you beinghomeless or to prevent you becoming homeless.

No Yes

- Main form

Are you claiming Second Adult Rebate only? No Yes

Do you, or your partner, have any children whoyou get Child Benefit for and who live with you?

No Yes

Do any adults usually live with you and your partner? NoBy adults we mean people over 16, including children whoyou do not receive child benefit for.

Yes

Are you or your partner getting or waiting to hear abouta claim for Income Support, Income-based Jobseeker'sAllowance, Income-related Employment and SupportAllowance or Guarantee Pension Credit?

No NoYes Yes

You Your partner

Are you or your partner self-employed No NoYes Yes

Do you or your partner work for an employer? No NoYes Yes

No NoDo you or your partner do any other work at all? Yes Yes

No Yes

Do you have a partner who normally lives with you? NoBy partner we mean someone you are married to or have aCivil Partnership with or lives with you as if you were married.

Yes

You must answer all of these questions before continuing with the application form.

No Yes

Opening Questions

How many bedrooms are there in the property?

Are you (please choose one box):

•

•

•

•

a private tenant?

a housing association or social landlord tenant?

a council tenant?

an owner-occupier?

Are you or your partner getting or waiting to hear aboutany other claims for benefits or pensions?Including Child Tax Credits, Working Tax Credits, StateRetirement Pension and Universal Credit.

This could be voluntary work or any other work, even if it is not paid work.

Are you of State Pension Credit age? No YesBy State Pension Credit age we mean the earliest age atwhich you can receive the basic State Pension

Do you own any of this property as part of a sharedownership scheme?

No Yes

Have you claimed or are about to claim Universal Credit? No Yes

As a condition of your tenancy, do you receive care support orsupervision at the property?

No

Please select one of the following:

I want to apply for both Housing Benefit and Local Council Tax Support

I want to apply for Local Council Tax Support only

I want to apply for Housing Benefit only

I want to apply for Second Adult Rebate only

- Main form

You Your partner

You Your partner

The council is committed to an Equal Opportunities Policy to promote equality and fair treatment in the provision of itsservices. In order to monitor the effectiveness of this policy, all customers completing an application form are asked tocomplete this form. This is voluntary and does not affect your application in any way.

Asian

British

Asian British

Irish

Bangladeshi

Other white

Indian

Kashmiri

Mixed

Pakistani

White and black Caribbean

Other Asian

White and black African

White and Asian

Black

Other mixed

Black British

Caribbean

African

Other black

Chinese

Other

Please specify: (You)

Please specify: (Your partner)







You Your partner

You Your partner



Ethnic Survey

White

You Your partner

You Your partner

- Main form Your claim

Your partner You

Surname or family name

Other names

Any other names you haveused

Title

Address, including roomnumber if you have oneDo not tell us your partner'saddress if it is the same asyours.

Postcode Postcode

What date did you moveto this address?

a council tenant?a private tenant? a housing association orsocial landlord tenant?

What you have told us so far:an owner-occupier?

Part 1 About you and your partner

Telephone Numbers

Date of birth

Home number

Work number

Mobile number

You are:

Do you have a partner who lives with you?

Do any adults usually live with you and your partner?

Are you claiming Second Adult Rebate only?

If there are any incorrect details above, please go back to Page 4 and amend your answers.

Are there any children in your household?

You:

Your partner:

Number of bedrooms in the property:

Claim Number / Reference If known

Council Tax Number / Reference If known

- Main form Part 1 About you and your partner - continued

Your partner You

National Insurance (NI) number

Please tell us about it below. Please tell us about it below.

When did you last claim?

Which council did you claim from?

What name did you use for the claim?

What address did you claim for?

Postcode Postcode

Please tell us your last address:

Postcode Postcode

Tell us your status at the address:

You and your partner'semail addresses

If you have moved from this address,have you told the council you claimedfrom?

Have you or your partner beenawarded Housing Benefit or helpwith your Council Tax before?

If you do not have an NI number,or cannot find it, tick here:

If your partner does not have an NInumber, or cannot find it, tick here:

No

Yes

No

Yes

No

Yes

No

Yes

Have you or your partner movedhome in the last 12 months?

No

Yes

No

Yes

i.e. the homeowner, a private tenant,a council tenant, lodger.

Find this on payslips or letters fromsocial security or the tax office. Wecannot normally decide your claim ifwe do not have your NI number.

Your partner

Part 1 About you and your partner - continued

You

Have you or your partnercome to live in the UK, theRepublic of Ireland, theChannel Islands or the Isleof Man in the last 5 years?

What is your nationality?

If your nationality is not British,on what date did you last enterand apply to stay in the UK?The UK is England, NorthernIreland, Scotland and Wales.

Are you or your partner inhospital at the moment?

Please tell us about it below.

When did you go in?

When will you come out, ifyou know this?

Do you or your partner getDisability Living Allowance?

Does anyone get Carer'sAllowance for lookingafter you or your partner?

Have you or your partnerever been told that you areentitled to Carer's Allowance,even if you do not receive it,because you are gettinganother benefit instead?

Please tell us about it below.

- Main form

We will write to you about this. We will write to you about this.

We will write to you about this.




No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

How much per week? How much per week?

P

P

P

P

Care component

How much? How often?

Mobility component


Do you or your partner getPersonal IndependencePayment?

No No

Yes Yes

How much? How often? How much? How often?

Daily living component

Mobility component

The UK is England, NorthernIreland, Scotland and Wales.

Do you or your partner getArmed Forces IndependencePayment?

No No

Yes Yes

Do you or your partner getAttendance Allowance?

- Main form Part 1 About you and your partner - continued

Your partner You

Are you or your partner a student?

How much of your income is takeninto account when working out yourgrant?

Tell us if this is full or part time.

Full-time Part-time

Do you or your partnerpay towards the upkeepof a student?

an apprentice

Do you or your partner havea vehicle from a MobilityScheme?

a year

Are you or your partner:

on work based training

Tell us if this is full or part time.

Full-time Part-time

a year

in legal custody

severely mentally impaired

registered blind or haveregained sight in the last28 weeks

long-term sick or disabled

We will contact you if weneed any more information.

How often?

By student we mean anyone who is attending a course of study at an educational establishment,including student nurses.

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

How much? How much? How often?

P

P

P

P

P

P

•

•

•

•

•

•

Have you or your partnerfostered a child, or becomean approved foster carer inthe last 12 months

P No No

Yes Yes

If yes, please supply proof of this, e.g. a letter from the fostering agency confirmingthe date you / your partner became an approved foster carer and the date a childwas last fostered.

- Main form Part 2 About children

We need to know about any children in your household who are:

under 16,

aged 16 to 18, or 19 and in education doing a course not higher than GCE A-level, SCE Higher level or GNVQ (advanced)

If there are more than four children, use the Extra Information page (Page 36). Tellus all the information we ask for on this page.

How many children are there in your household?

First child Second child Third child Fourth child

Last name

Other names

Date of birth

What is the child's sex?

Relationship to you

Relationship to your partner

Usual address, if differentfrom yours

Who gets the ChildBenefit for them?

aged 16 or 17 and registered for work or work-based training, or

Child Benefit number

Are there any childrenin your household asdescribed above?

Postcode Postcode Postcode Postcode

No

Yes

•••

P

We can use the information you provide in this section to generate an application for free schoolmeals if it appears that any children are eligible.

Please tell us the schoolthis child attends.

We can use the information provided in this section to generate an application for free school meals if it appears that anychildren are eligible. If you do not wish to apply for free school meals please tick this box If you do wish to apply for free school meals, please tell us the school each child attends when asked below and we willprocess your application.

If this child is notat school, pleasecheck this box:




- Main form Part 2 About children - continued

First child

Is the child registeredblind or regained sightin the last 28 weeks?

Does the child getDisability LivingAllowance? How much?

Do you or your partner payany childminding costs forthis child to a registeredchildminder, a nursery oran after-school club?

Tell usabout itbelow.

Tell us the name andregistration number ofthe minder / nursery.

How much do youpay a week?

a week

Second child

How much?


Third child

How much?


Fourth child

How much?


a week

How often?

a week a week

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Do you only pay forchild care duringschool term time?

No No No No

Yes Yes Yes Yes

P

P

Care component

How much?

Care component Care component Care component

Mobility component Mobility component Mobility component Mobility component

How much?

How often?

Does the childget PersonalIndependencePayment?

No No No No

How much? How much? How much? How much?Yes Yes Yes Yes

Daily living comp. Daily living comp. Daily living comp. Daily living comp.

How much?

How often?

Mobility component Mobility component Mobility component Mobility component

How much?

How often?

Does the child needtheir own bedroomdue to disability ormedical condition?

No No No No

Yes Yes Yes Yes

Please explain why:

Fifth child Sixth child Seventh child Eighth child

Last name

Other names

Date of birth

What is the child's sex?

The child's relationship toyouThe child's relationship toyour partnerUsual address, if differentfrom yours

Who gets the ChildBenefit for them?

Child Benefit numberPostcode Postcode Postcode Postcode

Is the child registeredblind or regained sightin the last 28 weeks?

No No No NoPYes Yes Yes Yes

Does the child getDisability LivingAllowance?

No No No NoPHow much? How much? How much? How much?Yes Yes Yes Yes

Care

How often?

Mobility

How often?

Do you or your partner payany childminding costs forthis child to a registeredchildminder, a nursery oran after-school club?

No No No NoYes Yes Yes Yes

Name and registration

How much do youpay a week?

a week a week a weeka weekP

Do you only pay for childcare during school termtime?

No No No NoYes Yes Yes Yes

Does the childget PersonalIndependencePayment?

No No No NoPHow much? How much? How much? How much?Yes Yes Yes Yes

Daily living

How often?

Mobility

How often?

Name and registration Name and registration Name and registration

Does the child need theirown bedroom due todisability or medicalcondition?

No No No NoYes Yes Yes YesPlease explain why and provide evidence from their GP or consultant P

- Main form Part 2 About children - continued

Please tell us the schoolthis child attends.





- Main form Part 3 About other people who live with you

Now tell us about all the people who usually live with you and your partner. Do not tell us about people who just share a hall, bathroom or toilet with you.

Do any adults usually live with you and your partner?

Fill in this section.By adults we mean people over 16 who nobody gets Child Benefit for.

How many adults?

First person Second person Third person

Last name

Other names

Date of birth

Do they get IncomeSupport, Income-based Jobseeker'sAllowance, Income-related Employmentand Support Allowanceor Pension Credit(Guarantee Credit)?

Do they get DisabilityLiving Allowance,AttendanceAllowance, PIP or AFIP?

Are they registeredblind or haveregained sight inthe last 28 weeks?

Are they a full-timestudent, a studentnurse, a care worker,an apprentice or onwork based training?

Tell us which Tell us whichTell us which

Their relationship to you or your partner

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Which one? Which one? Which one?

Which one? Which one? Which one?

National Insurance no.

P

P

P

P

You do not have to tell us this but it may help us deal with your claim more quickly.

How much per week? How much per week? How much per week?

PIP - Personal Independence Payment AFIP - Armed Forces Independence Payment

Gender

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

First person

Are they severelymentally impaired?

Are they in legal custodyat the moment?

Are they in hospitalat the moment?

How much?

When are theyexpected tocome out?

Tell us about itbelow.

Does this includemoney for food?

Does this includemoney for heating?

a week

Tell us theirearnings beforeany deductions.

Second person Third person

When did they go in?

When are they due tocome out (if you know)?

Do they normally work for16 hours or more a week?

No


Yes

a week



No


Yes

a week



Tell us aboutit below


- Main form Part 3 About other people who live with you - continued


No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

a week a week a week

How many hours do theynormally work a week?

P

P

P

P

P

Is this person an adult childof the claimant / applicant?

No No No

Yes Yes Yes

Are they currentlyserving in the armedforces and do theyintend to return tothis home afterdeployment?

P No No No

Yes Yes Yes

If yes, you will need to supply proof of this, for example a letter confirming that they arecurrently serving in the Armed Forces

- Main form Part 3 About other people who live with you - continued

Second person Third person

Do they have any other income at all?

1 Where does this income come from?

How much is it before deductions?





We need to see proof oftheir income.



Are they married to, or have a CivilPartnership with, or are living togetheras if they were married to any of thepeople who normally live with you?

Tell us thepartner's name.

First person

Make sure you tell us about all otherincome they have. This includes anybenefits or allowances you have nottold us about on this form and interestfrom savings and investments.

No

Yes

No

Yes

No

Yes

No

Yes




No


Yes

No


Yes

P

P

P

We call these people partner's Forename(s) Forename(s) Forename(s)

Surname Surname Surname

- Main form

Are you or your partner getting orwaiting to hear about a claim forIncome Support, Income- basedJobseeker's Allowance, Income-related Employment and SupportAllowance or Pension Credit?

Answer the questionsyou are asked below.

Are you or your partner actuallygetting Income Support, Income-based Jobseeker's Allowance,Income- related Employmentand Support Allowance orPension Credit at the moment?

Are you or your partner stillwaiting to hear about a claim forIncome Support, Income- basedJobseeker's Allowance, Income-related Employment and SupportAllowance or Pension Credit?

We must see evidence of your benefits, allowances or pension before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as evidence.

Answer the questionsyou are asked below.

You Your partner

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

You are waiting to hear about:

P

Which benefit are you getting? Which benefit is your partner getting?

When did you start getting it? When did your partner start getting it?

Your partner is waiting to hear about:

When did you claim? When did your partner claim?

About Income Support, Income-based Jobseeker's Allowance, Income-relatedEmployment and Support Allowance & Pension Credit

Part 4 -

- Main form Part 5 About being self-employed

Your partner

Are you or your partnerself-employed?

Answer all of the questions on thispage.

Answer all of the questions on thispage.

You must send us your trading accounts for the last financial year. If you have only recently setup the business and do not have a full year's accounts, we will need to see some other evidenceof your income. We will write to you about this.

What kind of work do youdo?

When did the businessstart?

What is the business nameand address?

Postcode Postcode

Do you have anybusiness partners?

Tell us their name and address.Tell us their name and address.

Postcode Postcode

How many hours a weekdo you usually work?

Do you get a BusinessStart-Up Allowance?

Do you pay into aprivate pensionscheme?

How often? How often?

We must see evidence of your earnings before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as evidence.

You

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

How much? How much?


P

P

P

No NoAre you a directorof this company?

Yes Yes

- Main form Part 6 About working for an employer

Your partner

Do you or your partnerwork for an employer?

Answer the questions on this page. Answer the questions on this page.

What kind of work doyou do?

What is your employer'sname and address?

Postcode Postcode

When did you start thisjob?

What is yourpayroll, employeeor staff number?

Are you (your partner)employed for a limitedperiod? When will you finish? When will you finish?

How often do you(your partner) getpaid?

How much do you(your partner) getpaid before tax andNational Insuranceare taken off?

How are you (yourpartner) paid?

When was your (yourpartner's) last pay rise?

When will your (yourpartner's) next payrise be?

You

No

Yes

No

Yes

No

Yes

No

Yes

How many employers?

P

If you or your partner work for more than one employer tell us about all the additional employerson the Extra Page (page 36).

For example, in cash, bycheque or into a bank orbuilding society account

- Main form Part 6 About working for an employer - continued

Your partner

How many hours a week do you(your partner) usually work?

Are you (your partner)getting Statutory Sick Pay(SSP), Statutory PaternityPay (SPP), Adoption Payor Statutory Maternity Pay(SMP) from your employerat the moment?

Are you (your partner) gettingany other sick pay or maternitypay from your employer at themoment?

Do you (your partner) payinto a private or companypension scheme?

We must see evidence of any earnings before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as evidence.

Do you (your partner)get tips or bonuses?

If you are unable to provide wage slips you should print the Certificate of Earnings form found at the end of this form (Extra Forms), and you and your employer should complete and return it to us.

How often?

You

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

When did this start?

When did this start? When did this start?

When did this start?

How much? How much? How often?


P

P

P

- Main form Part 7 About any other work

Your partner

Do you ( your partner)do any other work at all?

Answer the questions on this page. Answer the questions on this page.This could be voluntarywork or any other work,even if it is not paid work.

What other work do you(your partner) do?

What is the name andaddress of the personyou (your partner) dothis work for?

Postcode Postcode

When did you (your partner)start this work?

How many hours a week doyou (your partner) usuallywork?

Do you (your partner) getpaid?

If you only get expensesor tips, still select 'Yes'and give details.

Tell us about it below.Tell us about it below.

How much do you getbefore any deductions?

How often are you paid?

We must see evidence of any earnings before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as evidence.

You

No

Yes

No

Yes

No

Yes

No

Yes

If you or your partner work for more employers, tell us about the other employers on the ExtraPage (page 36).

P

P

- Main form Part 8 About other benefits and pensions

Are you or your partner getting or waiting to hear about a claim for any of the benefits and pensions you have readin the above list?

Tell us about these below - tell usthe full rate before any deductions.

You Your partner

How many of theabove do you needto tell us about?

Name of benefitor pension

Waiting to hear Getting now

How often?

By what method?



Are you or your partner getting or have claimed anyother benefits that are not listed above? If 'Yes', tell us about it on the Extra Page (Page 36)

No

Yes

No

Yes

No

Yes Tell us about these below - tell us thefull rate before any deductions.

How much?

How much?

How often?

By what method?

How much?

How often?

By what method?



Getting nowWaiting to hear

Waiting to hear Getting nowWaiting to hear Getting now

How much?

How often?

By what method?

Carefully read the list of benefits and pensions below

P

P

Adoption Pay Bereavement Allowance Carer's Allowance Child Benefit Child Tax Credit Contribution-based Jobseeker's Allowance Contribution-based Employment andSupport Allowance Fostering Allowance

• • • • • • • •

• • • • • • • • •

Guardian's Allowance Incapacity Benefit Industrial Death Benefit Industrial Injuries Disablement Benefit Maternity Allowance Personal Pension Income Pre 1973 War Widow's Pension Savings Credit Severe Disablement Allowance

• • • • • • • • •

State Retirement Pension Statutory Maternity Pay Statutory Paternity Pay Statutory Sick Pay Universal Credit War Disablement Pension War Widow's Pension Widow's or Widower's Benefit Working Tax Credit

1

2 Name of benefitor pension

P


P


P

- Main form Part 9 About other money coming in

Do you or your partner have any money comingin (or expect to have some money coming in)that you have not already told us about on thisform?

If No you do not have to fill in this page.

Answer the questions on this page.

This includes occupational pensions, work pensions and private pensions, maintenance or child support for you, yourpartner or any of the children you have told us about on this form, money from a trust fund, training allowances, a studentgrant or loan, and any cash payments. Also tell us about any money you get from people living in your house as boarders,lodgers or sub-tenants.

Other money 1 Other money 2 Other money 3

If other, pleasedescribe:

Who gets it?

How much?

How often?

How is this paid?

When did theystart gettingthis income?

When is theincome likelyto go up?

No

Yes

How many sources of other money?

A) Are you already getting some other money? No

Yes

P

You do not need to tell us about payments fromthe Independent Living Fund, the Eileen Trust,the MacFarlane Trust or the Skipton Fund.

Type of income

- Main form Part 9 About other money coming in - continued


B) Does anyone owe money to you or your partner?

Tell us about it below

What for?

How much?

Who is it owed to?

C) Are you expecting to get any money in the next 12 months?

Tell us about it belowE.g. a redundancy payment or a payment instead of notice or holiday

What for?

How much?

We must see evidence of any money coming in before we can decide how much help you can get. Read the evidence checklist on Page 39 to see what you can use as proof.

No

Yes

No

Yes

How many sources of expected money?

How many sources of owed money?


P

P

P

- Main form Part 10 About where you live

Do you own your home or have amortgage?

Go to the next question.

Go to Part 12.

Are you a council tenant? Answer the questions below.

Go to Part 11.

Caravan,mobile home

What sort of building do you live in?

Detached house

Flat in a house

Semi-detachedhouse

Flat in a block

Board and lodgings

Terraced house

Flat over a shop

Hotel

Maisonette

Bedsit or rooms

Detached bungalow

Residentialnursing home

Semi-detachedbungalow

Hostel

Residential carehome

Other - givedetails

Does your home have central heating?

Does your home have a garage? Does your home have a parking space?

How many floors are there?

Do you and your household occupyonly part of the building you haveticked?

Where in the building do you live?

At the front In the middle At the back

Does your home have a garden?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Studio flat Houseboat

Has your home been built or adaptedfor people with disabilities?

No

Yes

Have you or your partner been entitledto Housing Benefit in the 52 weeksbefore making this claim?

NoCould you afford the rent when youfirst moved in?

No

YesYes

Do you or your partner have a carerwho lives somewhere else, butprovides care overnight in your home?

NoHas anyone in your household diedwithin the last 52 weeks?

No

YesYes

Has your home been adapted forpeople with disabilities?

No

Yes

Council Tenants Only -

Private Tenants / Housing Association Tenants Only -

- Main form Part 10 About where you live - continued

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

Just for you andyour household

That you sharewith other people

How many rooms are there in thebuilding? (enter zero for none)

In the wholebuilding

Living rooms

Bedsitting rooms

Bedrooms

Bathrooms or shower rooms

Toilets

Kitchens

Other rooms (please specify)

Do you use your home for business purposes?

Do you have a main home somewhere else?

Tell us about it below.

What is the address?

Postcode

Do you pay rent on your main home?

How much?

How often?

No

Yes

No

Yes

No

Yes

NoDo you or your partner have a carer wholives somewhere else, but provides careovernight in your home? Yes We may contact you for further details about this.

Are you an ex offender subject to MultiAgency Protection Arrangements?

No

Yes

Have you been living in homeless hostelsfor three months or more and have beensupported to recover and resettle due toalcohol, substance abuse or mental healthproblems?

No

Yes

P

P

P

If your main home is somewhere else in the UKor abroad, select the Yes option, even if you donot pay rent for it.

- Main form Part 11 About rent

Do you pay rent for your home? Go to Part 12.

Answer the next question.

Do you pay rent to the council? Answer the questions below.

Go to Part 12.

Postcode

If your landlord has an agent, tell ustheir business name and address. By agent we mean the person ororganisation you actually pay your rentto.

Postcode

Are you, your partner, or any of your oryour partner's children related to yourlandlord or agent, or to your landlord'spartner or the agent's partner?

What is the relationship?

is my landlord'sor agent's

When did you start renting your home?

When did you move to this address?

What sort of tenancy do you have?

How long is the tenancy for? to

Choose Yes if you would pay rent butyou already get Housing Benefit.

For example, shorthold, assured tiedrent or something like this.

No

Yes

No

Yes

No

Yes

Surname

Forename

P

P

Is your landlord an individual oran organisation?By landlord we mean the personor organisation who owns theproperty you live in.

Individual

Organisation

What is your landlord's organisation/ company name, or individual nameand business address?

Company

Related includes related throughmarriage, even if the marriage hasended. Some examples are ex-wife,ex-husband, aunt, brother, daughter,father, grandson, grandmother,son-in-law or stepdaughter.

If you have not moved in yet, tell uswhen you expect to move in, then tellus when you have actually moved in.

- Main form Part 11 About rent - continued

What is the property let as? Choose the option that applies.

Furnished

Partly furnished

Hardly any furniture

Unfurnished

How much rent do youpay and how often?

How often?

Does anyone else sharethe rent with you and yourpartner? i.e. Joint tenants How many?

Tell us their names, theirrelationship to you and yourpartner and date of births.

How much of the rent dothey pay and how often?

How often?

Has your rent changed inthe last 12 months?

Send us proof of the date it changed and how much it changed.

Do you know when your nextrent increase is due?

We must see evidence of your rent and tenancy before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as proof.

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

Do you have any weeks whenyou do not have to pay rent?

How many in a year?

Are you behindwith your rent?

By how many weeks?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes On what date?

Surname First Name Relationship

P

P

P

P

P

Date of birth

Have you or your partnerbeen entitled to HousingBenefit in the 52 weeksbefore making this claim?

No

Yes

If you are under 22 yrs old, areyou, or have you been under acare worker or looked afterunder the Children Act

No

Yes

Has someone in yourhousehold died within thelast 12 months?

No

Yes

NoCould you afford the rentwhen you first moved in? Yes


Who has to pay the Council Taxbill for your home?

You and / or your partner

Your landlord

Tell us who it is.Someone else

Does your rent include money for the following?

Meals

How often?How much?

For which meals? Breakfast(Please choose.)

Lunch

Evening meal

Water authority charges


Heating


Lighting


Hot water


Fuel for cooking


Laundry


Cleaning rooms or windows


No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

P

P

P

P

P

P

P

P


Gardening

How often?How much?

Garage or parking space

How often?How much?

Do you have to rent the garage as part of your tenancyagreement?

Personal care and support

How often?How much?

Do you pay any service chargesseparate from your rent?


What for?

Are you living away from home atthe moment? Tell us about it below.

Why are you not living at home?

When did you last live at home?

When do you expect to go back home?

What is the address of whereyou are living at the moment?

Postcode

Have you sublet your home?

Who lives there now?

We must see evidence of your rent and tenancy before we can decide how much help you can get. Read the checklist on Page 39 to see what you can use as evidence.

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

P

P

P

P

P

e.g. for cleaning or lightingin shared areas, an alarmsystem, a warden, meals,or lift maintenance?

We need to know if you or your partner have any bank accounts, savings, investments or property in the UK orabroad. This includes cash, current accounts and savings accounts with a bank or building society, Post Office accounts,Premium bonds, National Savings Certificates, stocks and shares and dormant accounts.

How many accounts?

Bank accounts

Building society accounts

How many accounts?

Post Office accounts

How many accounts?

Premium bonds

How many? Total amount

Unit trusts, ISAs, PEPs,TESSAs or other investments

How many accounts?

Income bonds or capital bonds

How many accounts? Total amount

Money or property held in trust


Any other savings or investments


Type of other savings or investment

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Name of bank Account numberWhose name is the account in?

How much is in the account?

Whose name is the account in?

How much is in the account?Name of building society Account number

Whose name is the account in?

How much is in the account?Type of account Account number

- Main Form Part 12 About bank accounts, savings, investments and property

1.2.3.4.5.

1.2.3.4.5.

1.2.3.

Apart from your home, do you or your partner own any other property or land inthis country or abroad?

No

Yes

How much is in the account?

Whose name is the account in?Type of account Account number

1.2.3.4.

P

P

P

P

P

P

P

P

P

P

If it is mortgaged or loan, still choose Yes.

- Main Form Part 12 About bank accounts, savings, investments & property - continued

Do you, your partner or anychildren you are claiming forhave any National SavingsCertificates?

Do any of your savings orinvestments include:

You must provide as much proof as possible, however we may need to write to you.

money from the sale of a house, or

money from a charity?

Have you or your partner received:

Who received the payment?

a Far Eastern Prisoner of WarCompensation payment, or

You Your partner

a compensation payment made tovictims of atrocities that happenedduring the Second World War? You Your partner

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

Have you, your partner or any ofyour children you are claiming for,received a payment from the vCJD(Creutzfeldt-Jakob Disease) Trust?

No

Yes

No

Yes

No

Yes

No

Yes

NoDo you have any shares?

Name of the company the shares are held in Number of shares held

Yes

Approximate value

NoDo any of your savings or investmentsinclude any amount of deferredpension?

Yes Please provide details of accounts including the amount of deferredpension and the date received.

No

Yes Who received the payment?

Total amount

P

P

P

P

P

P

P

P

• •

•

•

- Main form Part 13 How you will be paid and the choices you have

Payment direct into an account

You agree to be paid direct into an account. Please complete Part B on this page for Private Tenants

Bank / Building Society Name

Account Holder Name(s)

Account Number

Branch

SortcodeRoll Number (Building Society only)

for Housing Association TenantsYou agree to be paid direct into an account. Please complete Part B on this page

Please provide details of your account below:

If you do not wish to provide details of your account on this electronic form, you may print out, fill andreturn the 'Account details' form found on page 45. If you wish to do this, please check this box:

For your convenience and security we recommend that payment is made direct into your bank / building society account.You can obtain advice on opening and running an account from any bank or building society of your choice. You can alsoget independent advice from the Citizens Advice Bureau. You may be able to use a cash machine, which will usually mean you can get your money at any time of the day or night.You can use most of these machines for free, but some of them will charge you to take your money out. If so, you will bewarned by a message on the screen. This will give you the opportunity to cancel your transaction without being charged. You can check your Housing Benefit payments on your account statements. If you think your payment is wrong, get intouch with the office that pays you.

Part A: Selecting your preferred payment option

Part B: Account Details

•

•

You would like payment to be direct to your landlord

Please print out the 'Direct Payments to your Landlord'form on Page 42, complete and return it to us, to explainwhy you want payments to be made to your landlord.

If there is a reason why you cannot manage yourown rent payments we may be able to pay yourlandlord directly. If so please select this option

- Main form Part 14 Backdating your award

We can usually make the award from the Monday after the date we receive your application. Sometimes we can make an award from an earlier date if you have good reason for not applying earlier. If you want us toconsider making an award from an earlier date, tell us when you want to apply from and why you did not apply earlier.

Date you want to apply from :

Tell us below why you have not applied before (please provide as much information as possible, together with anyevidence to support this). We will write to you if we need further information.

Do you wish to apply from an earlier date?

Part 16 Additional Questions

If you do not have a printer, after you have submitted this form, wemay send you printed documents for you to sign and return to us.

Is your computer able to print form pages? No

Yes

No

Yes

Part 15 Sharing Information With Your Landlord

For Private Tenants OnlySharing information with your private landlord could help us deal with your claim more quickly and reduce the risk ofyou 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 startdate of your tenancy. 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. If you give us permission by signing this form, we will only share information with your landlord if you have agreed that yourHousing Benefit can be paid direct to your landlord.

If you give us permission, we would be able to tell your landlord whether: - you have claimed or renewed your claim for Housing Benefit, or - we need more information to make a decision on your claim, and what that information may be, or - we have made a decision on your claim.

We will not give your landlord any information about: - your personal or household circumstances, or - your financial circumstances

You can withdraw your permission at any time.

It will not affect your claim if you do not give us permission to discuss your claim with your landlord.

NoDo you give us permission to discussyour claim with your landlord?

Yes

- Main form Part 17 Sharing information with other people

If you have someone who helps you such as a support worker or relative, it may help us to deal with your claim more quicklyif we are able to share information with them. Under the Data Protection Act 1998, we need your permission. Do you want to give us permission to share information with someone else? No

Yes

If yes, please give that person’s details below and complete the confirmation. You can withdraw your permission at any timeby writing to us.

Name of the person:

Address or organisation theywork for OR relationship toyou if they are a relative:

Daytime telephone number ofthe person:

I give Doncaster Council permission to share informationabout my claim with the person named above:

- Main form

Please use the space below to tell us anything else you think we should know about:

Extra Page

- Declaration Declaration

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

I declare that the information I have given on this form iscorrect and complete. I have checked the informationmyself or have had it read back to me.I understand that if I give information that is incorrect orincomplete, you may take action against me. This mayinclude court action.

I know that I must let you know in writing about anychange in my circumstances which might affect my claim.

Applicant'ssignature

Partner'ssignatureDate Date

I declare that as far as possible, I have confirmed with the claimant that the answers I have written on this form are correct.Name of the person who filled in the form

Signature

Relationship to the person claiming

Date

Name of applicant

Name of second applicant

Address for whichclaim is being made

Type of occupancy

If you are concerned about sending documents through the post you can visit one of our offices where staff will beable to verify the documents and return them to you.

As detailed throughout the form you are required to provide supporting evidence for your claim, details of which are found atPage 37. You may also be required to print, complete and return forms found at the end of the form (Extra Forms). Pleaseindicate whether this additional material will be returned with this declaration or separately:

All evidence /forms enclosed

Some evidence / formsenclosed, remainder to follow

All evidenceto follow

Please send this declaration, accompanying evidence,and additional forms to:

Ref. E-Signing Enabled: Date of E-Signing:

Even if someone has filled in this for you, you must sign this declaration if you can. If you have a partner, it wouldbe helpful if they sign below to confirm that all the details about them are correct, but they do not have to sign.

Telephone number Optional (helpful if we have a query)

I understand that you may use any information I haveprovided in connection with this and any other claim forsocial security benefits that I have made or may make. Thecouncil may give some information to other organisations,such as government departments, local authorities andprivate-sector companies such as banks and organisationsthat may lend me money, if the law allows this. I agree that you will use the information I have provided

Our Submission Reference:

When the form data has been submitted to us, please print this page.

Postcode

- Declaration Declaration

Applicant'sconfirmation

Partner'sconfirmation

Date Date

I declare that as far as possible, I have confirmed with the claimant that the answers I have written on this form are correct.

Name of the person who filled in the form

Confirmation

Relationship to the person claiming

Date

Name of applicant

Name of second applicant

Address for whichclaim is being made

Type of occupancy

If you are concerned about sending documents through the post you can visit one of our offices where staff will beable to verify the documents and return them to you.

Please send any accompanying evidence, and additionalforms to:

Even if someone else has filled in this form for you, you as the claimant, must check and complete the declarationbelow if you can. If you have a partner, getting them to check this declaration should allow us to process this claimmore quickly, but they do not have to check it. If your partner does check this form, they are agreeing to thedeclaration shown below.

Telephone number If possible (this helps us if we have a query)

Our Submission Reference:

Postcode

I understand that you may use any information I haveprovided in connection with this and any other claim forsocial security benefits that I have made or may make. Thecouncil may give some information to other organisations,such as government departments, local authorities andprivate-sector companies such as banks and organisationsthat may lend me money, if the law allows this.

I declare that the information I have given on this form iscorrect and complete. I have checked the informationmyself or have had it read back to me.I understand that if I give information that is incorrect orincomplete, you may take action against me. This mayinclude court action.I agree that you will use the information I have provided

I know that I must let you know in writing about anychange in my circumstances which might affect my claim.

As detailed throughout the form you are required to provide supporting evidence for your claim,further details of what you need to provide are found in the Evidence Checklist on Page 39.

You may also be required to print, complete and return Extra Forms found at the end of the form.

- Checklist Evidence Checklist

The following list is created as you fill in the form. It shows the categories of evidence you must provide in support of yourapplication. More details about what is acceptable as evidence are listed over the following pages (click the "Next" button toview this information). Please check that you have included all the evidence we need to process your claim - you can printthis page if you wish.

- Have you completed the claim form? - If required, have you provided extra information on the Extra Page (36)? - - Have you acknowledged any evidence you need to provide along with your claim? Tick here to confirm this - - Have you connected to the internet and submitted your form to us?

Official use only - Select here to edit above checklist (de-select to restore automated list):

Ref:

Override Checklist:

Are you aware of all the evidence we need to process your claim?Proof of your National Insurance numberYou must send / provide us an original document to confirm your and your partner's National Insurance number.You can find your National Insurance number on your:• P45;• P60;• Wage or salary slips;• Tax letter;

Proof of your and your partner's identityYou must prove your and your partner's identity before we can pay you any benefit. You must send us one form of identityas well as proof of your National Insurance number.Here are some examples of the original documents that we will accept as proof.• Bank statement (dated within four weeks before the date you make the claim)

Birth certificate (full or short)Certificate of employment in HM ForcesCertificate of employment in the Merchant NavyDivorce or annulment papersDriving licenceHome Office standard acknowledgement letter (SAL 1 or 2)Identity card issued by a European Community (EU), or European Economic Area (EEA) member stateLetter from your solicitor, social worker, probation officer or the Inland RevenueLife assurance policiesMarriage certificateMedical cardPassport (current and valid)UK Residence permitUtility bill (such as gas or electricity) paid in your name for the last quarterWage slips from current employer

•••••••••••••••

Proof of who lives in your home

For anybody else who lives with you as part of your family (but not a sub-tenant or lodger)Wage slips to show their earnings before deductions.Proof of any other income they may receive including benefits, private pension details and confirmation of interest theyhave received from their savings and investments.Proof that they are a student, on a government training scheme or an apprentice.

You must provide original documents as proof. We do not accept photocopies.

••

•

• Letters from the Department for Work and Pensions or Pension Service; or• National Insurance card.

- Checklist Info Details of evidence you must provide.

Evidence of income

Benefits and allowances

• The benefit advice letter telling you that benefit will be paid into your bank account.The advice letter must show the current rates of payment.

• Benefit payment card and receipt from a post office showing the amount of the last payment you received.• Current bank statements showing that the benefit has been paid into your bank account.• We need to see your letter confirming that you get Working Tax Credit or Child Tax Credit.

Pensions

• The Pension letter.• Current bank statements showing that the pensions (private or State Retirement Pension) have been paid into your

bank account.• A private or occupational pension advice slip or letter.

Other income• An award letter if benefit has just been awarded.• Court order award notices or Child Support Agency letters giving details of maintenance.• Letters from absent parents confirming maintenance they pay to you if no court order has been made.• Insurance policy or home income plan details.

You must provide original documents as proof. We do not accept photocopies.

Proof of investments and savings• Current bank or building society statements (do not forget to include this especially if your wages or benefits are paid into

this account). We cannot deal with your claim without these details.The statements must cover at least the last two months.

• Letter from the bank or building society confirming the details of the accounts.• Documents showing proof of ownership, for example statements showing assets for certificates, bonds, unit trusts, stocks

and shares, Premium Bonds, saving certificates and so on.

Proof of earningsWorking for an employer

• Proof of all earnings including:deductions from earnings for a private pension scheme;deductions from earnings for a superannuation scheme;details of Statutory Sick Pay or Statutory Maternity Pay included in the pay; and details of the number of hours worked.

• Proof of earnings must be one or more of the following.The last five pay slips if you are paid every weekThe last three pay slips if you are paid every fortnightThe last two pay slips if you are paid every month.

If you don't have any of the above, print the certificate of earnings form found at the end of this form (Extra forms). You andyour employer must fill in this form and return it to us. If you have just started your job and have not yet been paid, send in aletter from your employer with details of your expected earnings.

If your contributions to your private or occupational pension are shown on your pay slip, we will accept this as proof. If youhave made your own arrangements for a private or occupational pension, proof of your contributions must be the lateststatement from your pension provider.

- Checklist Info Details of evidence you must provide (continued).

Self-employed

• Your most recent accounts

• Partnership agreement if you have one

• Details of payments made to a private or occupational pension

• Tax assessments

If you don't have any of the above, contact your local council's Benefit Services and ask for a self-employed form.

Proof of rent

If you rent your home from the council, you do not have to provide proof of the rent you have to pay to the council.

If you are renting your home from a private landlord or housing association, you will need to send us one or more of thefollowing as proof.• Your current tenancy agreement

• Your rent books or receipts and a letter from your landlord or agent confirming the details of your tenancy

• The notice of registration form (RO5), if you have a protected or regulated tenancy

• Alternatively, your landlord can complete a landlord form, found at the end of this form (Extra forms).

Sub-tenants, boarders and lodgersIf you are renting part of your home to a sub-tenant, boarder or lodger you will need to send us a letter confirming how muchyou charge and when they moved in. You will also need to send us one of the following as proof that you are being paid rent.

• The tenancy agreement• The rent books or receipts.

StudentsMost full-time students do not qualify for Housing Benefit. By full time we mean more than 16 hours of guided learningeach week. The exceptions to this rule include students who are:

• disabled;

• over 60;

• those receiving Child Benefit for their children; or • under 19 and following a course of further education up to age 19.

You will need to send us original documents to prove your income from loans, grants, bursaries, deed of covenant and so on.The award letter from your education authority is the best proof of student income.

Full-time students are ‘disregarded’ for Council Tax. This means that they do not have to pay Council Tax. If only full-timestudents live in your property, you will not have to pay any Council Tax. Please contact your local council's Revenue Servicesfor more details.

Extra Forms Paying Benefit Direct to your Landlord Form

Address

Full name

Direct Payments to your Landlord

If none of the problems listed above apply, tell us why direct payments will cause you problems:

Ref:

Please return completed form to:

Part 1 About You

Part 2 About Your Circumstances

If you think that receiving Housing Benefit yourself will cause you serious problems, please completethis page and provide all the proof that we need to see.

Completion of this form does not guarantee that payments of Housing Benefit will go directly to your landlord, but it will help us decide if such payments are appropriate.

Each application will be assessed on its own individual merits. We will notify you and your landlord of theoutcome.Why do you think receiving direct payments will cause you serious problems? Please tick all that apply:

I have learning disabilities that make it difficult forme to manage my finances. - We need to seewritten proof from a social worker, supportworker, GP etc.

I have serious difficulties with reading andwriting. - We need to see written proof fromsupport organisations.

I do not speak English. - We need to see writtenproof from support organisations.

I am unable to open a bank account or I amoverdrawn. - We need to see letters from banksor money advisors showing this.

I have a history of non-payment of rent. - Weneed to see rent records and letters providingattempts to recover arrears, or proof from aprevious landlord.

I am dealing with an addiction to drugs, alcoholor gambling. - We need to see written proof fromsocial services, GP, hospital, care workers,support organisations etc.

My landlord wants direct payments in return forsetting my rent at or below my Local HousingAllowance Rate.

Please complete the Customer Declaration at the top of the next page

I have a medical condition or a mental healthproblem which makes it difficult for me to managemy finances. - We need to see written proof froma social worker, support worker, GP etc.

I have a history of homelessness. - We need tosee written proof from support organisationssuch as Housing Options or M25.

I am in rent arrears. - We need to see your rentbook or a letter from your landlord.

I have severe debt problems. - We need to seeCourt Orders, CCJ's, proof from help groups,solicitors, creditors, debt advisors, etc.

I am an undischarged bankrupt. - We need tosee a copy of the Court Order.

I have recently been released from prison. - Weneed to see written proof from the prison orProbation Service.

I am fleeing domestic violence. - We need to seewritten proof from support organisations.

Page 1

Postcode

Extra Forms Paying Benefit Direct to your Landlord Form

Signature of Person Claiming

Date

Landlord's Full Name

Landlord's Company Name (if applicable)

Landlord's Address

Postcode

Declaration

Direct Payments to your Landlord

Ref:

Part 3 Customer Declaration

Page 2

Part 4 To be Completed by your Landlord

I agree to notify Doncaster Council's Benefits Section in writing of any changes regarding my tenant'scircumstances that I become aware of, for example:

• a rent increase / decrease, • the tenant moves out, or • any other changes that I become aware of that affect the benefit I receive.

I understand that by law:

• I can be prosecuted, or face other action, if I accept Housing Benefit that I know I am not entitled to. • If you pay me too much Housing Benefit for my tenant, I must repay it. You can take the amount of overpaidbenefit from the benefit I get from other tenants. This will not affect their rent.

Landlord's Signature

Date

Please complete the details below for the bank or building society into which you would like the HousingBenefit paid.

Please write the name or names as they appear on the cheque book, passbook or statement

Sort Code - -

Account Number

If it is a building society account, what is the building society roll or reference number?

Name of bank or building society

Address of bank or building society

Postcode

Whose name or names is the account in?

Private and confidential

Extra Forms Certificate of Earnings Form

To be filled in by the employeeYour name Your employee or works no.

Address Your National Insurance no.

Your job

Your signature

To be filled in by the employerI would be grateful if you could help your employee by filling in the details below and returning the form to them.

If you hold a National Insurance number which is different to that shown above, please state it in the box below.

National Insurance number

Please tick the correct box to show how often the employee is paid. If 'Other' applies, please state the period.

Every week Every two weeks (fortnightly) Every four weeks Every calendar month

Other (please give details)

Please describe how you pay the employee (for example,cash, cheque, direct into bank account).

Normal Basic Pay Normal Hours Worked

Pay details for the last five weeks, three fortnightly, two calendar months or four weeks. (Include overtime, bonus, SSP, SMP and so on).

Occupational orpersonal pensioncontributions

Pay Period Ending Number of hours worked

Gross pay (before deductions)

NI contributions Tax paid byemployee

Please say here if Statutory Sick Pay or Statutory Maternity Pay is included

Your name YourbusinessaddressYour business

nameYour businessphone numberI confirm the information given is true and correct

Your signature Please place the business'authorisation stamp hereYour position in

the business

Postcode

Please return the completed form to:

Ref:

You should print and complete this form if you, your partner or any other adult who lives with you cannot provide payslipsfor their work. Please return the completed print out to the address shown below.

Extra Forms

Payment into an account

Building society savings account - not a cheque or mortgage account

What name or names is the account in?


Account number

Bank or building society cheque account or bank deposit account - not a mortgage account

Roll number


Branch Sort code

Account number

National Savings Bank investment account - not an ordinary account

Type of account - for example, a deposit or currentaccount

Account number

Tick one box only to say what type of account you want your money paid into. Then fill in the details of the account.

Address

Full name

Please pay any Housing Benefit I may be entitled to by the method I have selected. I understand that once I have selecteda payment method, it will not be changed without written instructions.

Your Signature:Date:

Postcode

Please return this completed form to:

Bank Account Details

Ref:

You should print and complete this form by hand as you have told us you don't want to provide your account details on theelectronic form. Please return the completed print out to the address shown below.

- Main form

You should now have:

Form completion

• Filled in and completed the application form.

• Been made aware of any proof you need to provide to support your application. Please refer to the evidence checklist tosee what proof you need to provide.

•

Remember that we need to see original documents, not photocopies, but you should not send valuable documents suchas bank books or passports by post. Instead you should bring them into your local contact point where they will get theinformation they need and return the documents to you.

You are at the end of the main form. Please go back through it and check your answers -click on the Show Errors button to highlight any omissions or mistakes.

Once the form has been checked and is free of errors, you should submit your completedform to us.

Extra Forms

Please use the space below to record the changes made to the initial form.

Alterations

NoDoes the customer have a partner? Yes

Preliminary Form - Customer Details

Partner Claimant

Surname or family name

First names

Any other names

Title

Address

Postcode Postcode

Daytime phone number

Home WorkWhat is this number? Home Work

Mobile Textphone Mobile Textphone

Date of birth

Callback arrangements / Case notes

You do not have to tell us this,but it may help us to deal withyour claim more quickly.

For office use onlyCustomer Name(s) Address

Date/Time Submitted Date of E-Signing:

Data Validation Ref

Do you have savings andinvestments of more than£16,000?

RBV Unedited Checklist

RBV Matched Claims

E-Form Status Page - for official use only

Form file name:

Form data set reference

Current Date

Date FromHas been E-Signed Date/Time E-Signed

Date/Time Submitted to main server

Expert for this form

Date/Time Submitted to external serverData Validation Reference

Form DatabasePrimary Record ID Secondary Record IDDepartment Name

Depart Classification / Priority

User Classification

Dept Case Reference

User Record Id

Date Record Started

Date Last Modified

Title

Tel No

First NameSurname

Date/Time form Started

Pages active with dynamic paging

Data Locked for Editing

Type of form - ufx, wdf or txt

Current User

System Data

If TXT - Optimised for screen-readers

Form Status

Victoria Forms

Form Design SettingsUse page titles for page menu

Enable top controls on opening

Start page for expert users

Last visible page: Unregistered users Registered users:

After ESigning/Submission- go to page No?

Enable high-quality print (WDF)

Dynamic paging enabled

Pages with forced error checkingPages that override forced error checking

Form History

Case Notes

Case Overview

Receipt Email Address Notification Email Address

Receipt Email Subject Notification Email Subject

Receipt Email Message Notification Email Message

Automatic Messaging

Page no for thumbnail

ESigning isavailable

Expert users:

Date of offline forms creation

Default branding file:

Shared Data Dictionary

Overide for TXT version

e.g. 'UK Revenues & Benefits Branding (1.0)'

e.g. 'Victoria Forms UK Government Data (1.0)'

Version 12/10/11

HTML pages within WDF

Mobile Number

TXT form isavailable

Print Collation Config

Portal Username

Email address Address

SearchField 3