Application for Housing Benefit, Council Tax Rebate,
Second Adult Rebate and Council Tax Discount
Benefits and Council Tax, PO Box 18015, Glenrothes, KY7 5YJ
Phone : 08451 55 11 55 Email: [email protected] www.fifedirect.org.uk
Name:
Address with Postcode:
For office use only
Claim Reference:
Issue Date:
Return Date:
Please complete this form and return it immediately to the address above or to your nearest
Local Office
If you choose to return your form to a Local Office, we recommend you make an appointment.
Although it is not always necessary this will ensure you receive the best possible service.
To arrange an appointment please call 08451 55 11 55
Please tell us what you want to claim by ticking the appropriate box.
Housing Benefit and Council Tax Rebate
Home Phone No:
Second Adult Rebate
Mobile Phone No:
Tick the boxes that apply, are you:
Email Address:
a Council tenant
renting from a private landlord
a Housing Association tenant
a home owner or paying a mortgage
a joint tenant
a joint owner
How to fill in this form
Housing Benefit and Council Tax Rebate
If you are claiming Housing Benefit and Council Tax Rebate please fill in all sections writing nil or none where appropriate.
You must return the form by the date shown on the front page or you may lose benefit. Under the Civil Partnership Act
2004, same gender couples make a joint claim. Please complete this form with black ink.
You can get help filling in this form by going to any Local Office. Or, you can phone 08451 55 11 55. You can
also get help at a Citizens’ Advice and Rights Fife Council Office (CARF).
Please remember to enclose all the documents we ask for, but do not send benefit or savings books by post.
You can take them to your Local Office where we will copy them.
We do not need proof of your income and savings if you receive Income Support, Job Seeker’s Allowance (income based)
or Employment and Support Allowance (income related). If you do not have all required evidence you should still hand
your form in to your Local Office or you may lose benefit.
Second Adult Rebate
If you are single and you have other people, aged 18 years or above, living with you, you do not get a 25% discount.
If the other person is on a low income, you may be entitled to a Second Adult Rebate on your Council Tax.
This is based on the other person’s income, not yours.You should fill in section 1(a), 1(b), 4 and 17.
You are not entitled to Second Adult Rebate if the other person is a lodger, boarder or sub-tenant.
Discounts
If you live alone you are entitled to a 25% Sole Occupancy Discount on your Council Tax.
If you do not live alone but members of your household are students, student nurses, apprentices, skillseekers, on a
youth training scheme, are in prison or in hospital, or have a severe mental impairment, you may still be eligible for a discount.
What happens next?
We will work out your benefit and write to you telling you how much you will get and when it will start.
Please check all these details. If you disagree with our decision, you can write to us within one month of the date of
our letter, so that we can reconsider your claim.
You can ask us to look at your claim again and you may appeal to an independent tribunal if you are still not satisfied.
Changes in circumstances
You must tell the Benefits and Council Tax Team straightaway of any changes in your circumstances, particularly changes
in the money you have coming in, your savings or changes to the number of people in your household.You must tell
the Benefits and Council Tax Team of any changes in writing or by visiting your Local Office or telephone
08451 551155. It is an offence not to tell us about any change that affects your benefit.
Backdating – under pension credit age
We can usually award benefit from the Monday after we receive your claim. Sometimes we can pay benefit from an
earlier date, but you must have a good reason for not claiming earlier.
If you are under 60 we can consider backdating your claim for up to 6 months.
If you want us to consider backdating your claim, you must write to us, giving your reasons for not applying at the
appropriate time.The reasons you give must apply throughout the period you want backdated benefit for.
Not knowing you could apply does not count as a good reason.You can use the space in Section 16 to write to us.
We will consider your claim and get back to you with our decision.
Backdating – over pension credit age
If you are aged 60+ then the claim automatically covers the previous 3 months from the date it is received - provided
you had a liability to pay rent or council tax during that period. Furthermore, if you become 60 within that period
it will only be paid from the date of your 60th birthday
Discretionary Housing Payment
If you are entitled to Housing Benefit or Council Tax Rebate we can make short term payments if we believe you need
extra financial help due to unexpected circumstances.
If you are receiving Housing Benefit or Council Tax Rebate and you are unable to pay the rest of your rent or Council
Tax, please phone us on 08451 551155 for more information or to ask for an application form.
Local Housing Allowance (LHA)
From 7 April 2008 the way Housing Benefit is paid for private tenants changed. You will be paid Local
Housing Allowance (LHA), if you make a new claim for Housing Benefit on or after this date and you rent your house
from a private landlord.
Under this scheme you will receive a standard allowance based on the size of your household and the area in
which you live.These allowances will be published monthly, in advance, so that you can find out how much rent
Local Housing Allowance will pay before you rent a property.
As well as changing the way Housing Benefit is calculated, this system changes the way it is paid to private tenants.
Housing Benefit will usually be paid to you the claimant and you will no longer be able to choose to have payment
made to your landlord.
The circumstances where the Council will consider paying LHA direct to landlord are where the claimant is unable
to pay their rent because they have difficulties managing their own affairs or it’s unlikely the claimant will pay their rent.
Consideration for direct payment to landlord will be where the landlord is prepared to reduce the rent to an affordable
level for the tenant (usually at the Local Housing Allowance level) and where the tenant agrees to have the LHA paid
to the landlord.
Payment can be made to the landlord direct if a tenant has eight weeks arrears or more. This is a statutory safeguard.
Overnight Care - If you are a private tenant you may be entitled to an increase in Local Housing Allowance if you have
a carer who lives somewhere else, but provides care overnight in your home.
Housing Benefit will be paid directly into a bank account via BACS and you should then set up a regular payment to
your landlord.
For more information and to check the Local Housing Allowance rates you can go to www.fifedirect.org.uk
2
Section 1
Personal details
1(a)
Title
Surname
First name
Date of birth
You
/
/
Your partner
/
/
Sex
Marital status
You
Your partner
Please give details of any other surnames you have used:
What is your nationality?
Have you come to live in the United Kingdom
in the last two years?
If ‘Yes’ tell us when (we may write to you for more information)
.
No
Yes
/
.
.
No
/
Yes
/
.
/
Evidence
You must provide us with two forms of identity for you and your partner.These must show a combination of
name, address, and signature, for example, birth certificate, marriage certificate, passport, medical card,
driving licence, UK residence permit or recent household bill.
The documents must be originals.You can take them to your Local Office.
1(b) National Insurance number (NINO)
You
Your partner
Evidence
You can find this on payslips, benefit order book, letters from the Department for Work and Pensions (DWP)
or the Tax Office. If you do not have a NINO contact the DWP.
The documents must be originals. You can take them to your Local Office.
We may not be able to make a decision on your claim if we do not have proof of your NINO.
Please answer the following questions:
1(c) Hospital
Have you been in hospital since you
filled in your last form?
You
No
Your partner
.
Yes
.
No
.
Yes
When did you go in?
/
/
/
/
When were you, or when do you
expect to be, discharged?
/
/
/
/
.
Name of the hospital?
1(d) Overnight Care
Do you or your partner have a carer who lives somewhere else, but provides care overnight in your home.
You
(This applies to private tenants only)
No
How often does the person provide care?
.
Your partner
Yes
.
No
.
Yes
/
.
/
You may be asked for further information about this.
3
1(e) Full-time education
You
Your partner
.
.
.
.
Are you a student?
No
Do you study full time or part time?
Name of the college or university:
Full time .
Give the term dates for the academic year:
From:
/
/
From:
/
/
To:
/
/
To:
/
/
Yes
Part time .
No
Yes
Full time .
Part time .
Do you receive access fund, hardship fund
or any income from a discretionary rent fund?
No
.
Yes
.
No
.
Yes
.
Do you receive a student loan, grant or bursary?
No
.
Yes
.
No
.
Yes
.
Evidence
You must send us evidence of your term dates, all bursary, SAAS, loan, grant, hardship fund or discretionary
rent refund award letters, etc.
The documents must be originals.You can take them to your Local Office.
1(f)
Attendance Allowance and Disability Living Allowance
Do you or your partner receive any of the following?
You
Your partner
Amount
Attendance Allowance
No .
Yes .
£
No .
Yes .
£
Disability Living Allowance (care component)
No .
Yes .
£
No .
Yes .
£
Disability Living Allowance (mobility component)
No .
Yes .
£
No .
Yes .
£
Vehicle from Motability Scheme
No .
Yes .
No .
Yes .
Amount
Evidence
You must provide proof of the benefit you receive, for example your award letter. The documents must be
originals.You can take them to your Local Office.
1(g) Carers Allowance
You
Does anyone receive Carers Allowance
for looking after you or your partner?
If ‘Yes’, when did it start?
No
Your partner
.
Yes
/
/
.
.
Yes
/
/
No
.
Yes
.
No
.
Yes
.
No
.
Who receives the Carers Allowance?
Where do they live?
Has the DWP told you or your partner that you are entitled to Carers Allowance
but you do not get it because of other benefits or allowances you receive?
1(h) Does any of the following apply to you or your partner?
(Please tick appropriate boxes and give dates)
On a training
Apprentice
Skillseeker
On remand
scheme
You
From:
To:
Your partner
From:
To:
If you are registered blind, please send your registration document.
* If you are severely mentally impaired, we may write to you about this.
4
Registered
blind
Severely mentally
impaired *
N/A
N/A
Section 2
Please fill in or tick all the boxes which apply to you
2(a) If you are a joint owner or tenant, please give the name
of the other owner or tenant:
2(b) If you moved in within the last 12 months
please give the date.
If your tenancy began within the last 12 months
please give the start date.
2(c) Have you or your partner claimed Housing Benefit
or Council Tax Rebate before?
/
/
/
/
You
.
No
Your partner
Yes
.
No
.
Yes
.
If ‘No’ go to question d.
If ‘Yes’ when did you claim?
/
/
/
/
What address did you claim at?
Were you the owner, tenant or lodger at that address?
Was this your last address?
.
No
Yes
.
No
.
Yes
.
If ‘No’ what was your last address?
When did you leave that address?
2(d) If you are applying for Sole Occupancy Discount on
Council Tax, what date do you want to apply from?
/
/
/
/
/
/
If you are applying for Sole Occupancy Discount because
someone has moved out, tell us their name and new address:
2(e) Are you living away from home at the moment?
No
.
.
Yes
If ‘Yes’ please give your current address:
Tell us why:
When did you last live at home?
/
/
When do you expect to return home?
/
/
/
/
If your home has been sublet, tell us who lives there now:
When did they move in?
5
Section 3
Dependant Children
No
Are there any children in your household?
.
Yes
.
If ‘No’, please go to section 4
If ‘Yes’, please give details below. (If you need more space, please continue on a separate sheet)
Please give details of all children who you receive Child Benefit for:
Surname
First name
Relationship
to you or
your partner
Date of
birth
Are they in
full time
education
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
Child
benefit
number
Date the
benefit
will end
Are any of the children named above registered disabled or blind?
If ‘Yes’ what are their names?
No
.
Yes
.
If ‘Yes’, do you or your partner receive Disability Living Allowance on behalf of them?
You must send us proof of this.
No
.
Yes
.
Do any of the children above have savings over £3000?
If ‘Yes’ what are their names?
No
.
Yes
.
Yes
.
You must send us proof of each child’s savings.
Do you pay a registered childminder, nursery or after-school club any childminding costs for looking after
your children?
No .
If ‘Yes’, give the name and registration number
of the childminder:
Evidence
You must provide proof that you are receiving Child Benefit for the children who live with you.This can be
your award letter if Child Benefit is paid into your bank, building society or savings account.
The documents must be originals.You can take them to your Local Office.
You must provide proof of any payment you make for any registered childcare scheme. Please send proof of
how much you pay. If this varies at any time additional proof must be provided.
6
Section 4
Others living in your household
No .
Apart from yourself, your partner and any dependant children, does anyone else live in your home?
Yes .
If ‘No’, please go to section 5
If ‘Yes’, please give details below. (If you need more space, please continue on a separate sheet)
Person 1
Person 2
Person 3
/
/
/
Surname
Other names
Relationship to you
or your partner
Date of birth
/
/
/
NINO
Are any of the people named above married to each other or living together as if they were married? No .
If ‘Yes’, tell us their names:
.
is the partner of .
Person 1
Are they receiving Income Support?
No .
Date it started:
Are they receiving Jobseekers
Allowance (income based)?
/
No .
Date it started:
Are they receiving Jobseekers
Allowance (contribution based)?
Yes .
/
No .
Date it started:
/
Yes .
Person 2
No .
/
Yes .
/
No .
/
Yes .
/
No .
/
/
Yes .
Person 3
No .
/
Yes .
/
No .
/
Yes .
/
No .
/
/
Yes .
/
Yes .
/
Yes .
/
What type of income do they receive? (for example, State Benefit,Work Pension,Tax Credit and so on)
Do not include Disability Living Allowance or Attendance Allowance.
Type of income:
Amount each week:
£
Do they work?
No .
£
Yes .
£
No .
Yes .
No .
Yes .
How many hours do they work each week?
What are their gross weekly earnings
before deductions?
£
Are they a student?
No .
Yes .
No .
Yes .
No .
Yes .
Are they in prison?
No .
Yes .
No .
Yes .
No .
Yes .
£
£
If ‘Yes’, when did they go in?
/
/
/
/
/
/
When will they be released?
/
/
/
/
/
/
7
Person 1
Have they gone into hospital since
you last filled in the form?
If ‘Yes’, when did they go in?
When do they expect to come home?
No .
Person 2
Yes .
No .
Person 3
Yes .
No .
Yes .
/
/
/
/
/
/
/
/
/
/
/
/
Are they retired?
No .
Yes .
No .
Yes .
No .
Yes .
Are they a skillseeker?
No .
Yes .
No .
Yes .
No .
Yes .
Are they an apprentice?
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
No .
Yes .
Are they on a training course?
Do any of the people named above pay rent to you or your partner?
If ‘Yes’, please tell us how much their rent is and how often it is due:
Person 1
Person 2
Person 3
Rent
How often?
No .
Do you provide meals?
Yes .
No .
Yes .
No .
Yes .
Evidence
You must provide proof of all income before deductions.
The documents must be originals.You can take them to your Local Office.
If you don’t provide the documents we may have to take the maximum non dependant deduction from your benefit.
Section 5
Income Support, Jobseekers Allowance (income based) and
Employment and Support Allowance (income related)
5(a) Are you or your partner getting Income
Support or waiting to hear about a claim for
Income Support?
You
No .
Yes .
Your Partner
No .
Yes .
If ‘Yes’, when did it start?
/
/
/
/
If waiting to hear about a claim, when did you claim?
/
/
/
/
5(b) Do you or your partner receive Jobseekers
Allowance (income based)?
No .
Yes .
No .
Yes .
If ‘Yes’, when did it start?
/
/
/
/
If waiting to hear about a claim, when did you claim?
/
/
/
/
5(c) Do you or your partner receive Employment
and Support Allowance (income related)?
No .
Yes .
No .
Yes .
If ‘Yes’, when did it start?
/
/
/
/
If waiting to hear about a claim, when did you claim?
/
/
/
/
We do not need to see proof if you receive Income Support, Jobseekers Allowance (Income Based) or
Employment and Support Allowance (Income Related).
If you receive Income Support, Jobseekers Allowance (Income Based) or Employment and Support Allowance
(Income Related), please go to section 12.
8
Section 6
Pension Credits
You
Do you or your partner receive a Pension Credit?
No .
Yes .
No .
Your Partner
Yes .
No .
Yes .
No .
Yes .
If ‘Yes’ please complete the following:
Do you or your partner receive a Guarantee Credit?
Date it started:
/
/
No .
Do you or your partner receive a Savings Credit?
Yes .
/
Date it started:
/
/
No .
/
Yes .
/
/
If you provide your full award letter your claim may be dealt with more quickly. If you receive Guarantee Credit
please go to section 12.
Section 7
Self-employed
You
Your partner
Are you or your partner self-employed?
No .
Yes .
What type of work do you do?
.
.
Name and address of the business:
.
.
Do you use part of your home
for business purposes?
No .
Yes .
No .
No .
What are your average weekly earnings?
£
£
What are your average weekly tips?
£
£
Yes .
Yes .
Evidence
If you are self-employed, enclose a copy of up-to-date self employed accounts. If you do not have accounts
contact your Local office and they will provide you with a self-employed questionnaire to fill in.
Any documents must be originals.You can take them to your Local Office. Alternatively you can
phone 08451 551155 and a questionnaire will be issued.
9
Section 8
Earned income
Do you or your partner have any earned income?
No .
Yes .
If ‘Yes’ please complete the following questions writing ‘nil’ or ‘none’ where appropriate.
You
Main job
Your partner
Second job
Main job
Second job
Employer’s name
Employer’s address
Payroll number
How many hours do you work?
How much do you get paid?
£
(gross earnings)
How often do you get paid?
(weekly, monthly and so on)
How often do you receive a bonus? every
How much is it?
£
How are you paid?
(cash, bank transfer, cheque and so on)
Date your employment started
/
Is the employment permanent?
No .
If ‘No’, when will it end?
/
£
£
£
every
£
every
£
every
£
/
/
Yes .
No .
/
/
/
Yes .
/
/
No .
/
Yes .
/
/
/
No .
/
/
Yes .
/
Job title
When is your next pay rise due?
Are you receiving Statutory Sick pay,
No .
Statutory Maternity pay or
Statutory Paternity pay?
Adoption Pay
Yes .
£
No .
Yes .
No .
Yes .
No .
Yes .
£
£
What are your average weekly tips?
Do you do any other work?
No .
If ‘Yes’, please give details and send payslips.
.
£
Yes .
No .
Yes .
.
Evidence
If you are paid weekly, please send your last five weekly wage slips.
If you are paid fortnightly, please send your last three wage slips.
If you are paid monthly or every four weeks, please send your last two wage slips.
Or, if you do not have the wage slips we need, ask your employer to fill in a certificate of earnings.
These are available from your Local Office or from the Benefits and Council Tax team. Telephone 08451 551155
All wage slips you provide must be originals.You can take them to your Local Office.
10
Section 9
Other income
9(a) Do you or your partner have any other income?
No .
Yes .
If ‘No’ please complete questions 9(b) and 9(c).
If ‘Yes’, please fill in all boxes.Write ‘nil’ or ‘none’ where appropriate.
We need to know the gross amounts (these are the amounts before any deductions)
Your
Partner
You
How often
is it paid?
Adoption Allowance
Annuities
£
£
every
£
£
every
Bereavement Allowance
£
£
every
British Coal Pension
Carers Allowance
£
£
£
£
every
every
Cash instead of concessionary coal
Child Benefit
£
£
£
£
every
every
Child Tax Credits
Employment and Support Allowance
Assessment Phase
Employment and Support Allowance
Main Phase
Work related component
Support component
£
£
£
£
every
every
£
£
£
£
every
every
Fife Council Pension
Government Training Allowance
£
£
£
£
every
every
£
£
£
£
every
every
£
£
every
£
£
£
£
every
every
£
£
every
£
£
every
Local Government Pension
£
£
every
Maintenance payments received
£
£
every
Maternity Allowance
£
£
every
Reduced Earnings Allowance
£
£
every
Royalties
£
£
every
Severe Disablement Pension
£
£
every
State Retirement Pension
£
£
every
War Disablement Pension
£
£
every
War Pension
£
£
every
War Widow’s Pension
£
£
every
Widowed Mother’s
Parents Allowance
Widow’s or Widower’s Benefit
£
£
every
£
£
every
Working Tax Credits
£
£
every
Works Pension
£
£
every
Incapacity Benefit
Industrial Death Benefit
Industrial Disablement Benefit
Industrial Injuries Benefit
Invalid Care Allowance
Job Release or
Early Retirement Pension
Jobseeker’s Allowance
(contribution based)
How is it paid?
(by order book,
into bank and so on)
11
9(b) Do you or your partner have
You
any other money coming in?
No
Your partner
Yes
No
Yes
If ‘Yes’, tell us what type of income it is:
How much do you receive?
£
£
How often is it paid?
You must tell us about all money coming into your household. We may ignore some of this when
we work out your benefit.
9(c) Are you or your partner waiting to hear whether you are entitled to any state benefit? No
Yes
.
If ‘Yes’, what type of benefit?
You
Your partner
When did you claim?
You
Your partner
Do you or your partner receive any income from a Voluntary Service, for example, the Territorial Army,
the Coastguard, or the Fire Service?
You
Your partner
No
Yes
No
Yes
If ‘Yes’, tell us what type of income it is:
How much do you receive?
£
£
How often is it paid?
Evidence
You must provide proof of all income you receive, for example your award letters.
The documents must be originals.You can take them to your Local Office.
Section 10
Payments you make
10(a) Do you or your partner pay into a private or company pension scheme?
You
No .
Yes .
No
If ‘Yes’, how much?
£
£
How often do you pay this?
every
every
.
Your Partner
Yes
.
Evidence
You must provide proof of the payments you make. Please provide your original letter of confirmation from
the pension provider or your annual statement.
You can take them to your Local Office. If you pay into a company scheme your payslips will be suitable proof.
10(b) Do you or your partner pay money towards a student grant?
You
No
If ‘Yes’, how much?
£
.
Yes
.
Your Partner
No
£
Evidence
You must provide proof of any payments you make, for example, the grant award letter.
The documents must be original.You can take them to your Local Office.
12
.
Yes
.
Section 11
Savings and Investments
11(a) Do you or your partner have any bank accounts, savings or investments in the UK or abroad? This includes bank or
building society current accounts, even when the accounts are empty or overdrawn.
No .
Yes .
If you answer Yes ALL boxes must be completed with the amount in your account OR ‘nil’or ‘none’ input.
Name of bank, building
society or credit union
Sort
Code
Account
Number
You
Your partner
Bank accounts
(current or deposit)
£
£
Building society
accounts
£
£
£
£
Credit union account
£
£
Income Bonds
£
£
ISA’s
£
£
Post office accounts
£
£
£
£
£
£
Cash savings
Premium Bonds
Tessa’s
If your Savings and Investments are over £16000.00 there is no entitlement to Housing Benefit and/or Council Tax
Rebate.
13
11(b) Do you or your partner have any national saving certificates?
Number of units
Number of units
No
Issue number or type
Issue number or type
Yes
No
Type of stock
.
Yes
.
Name of company
Do you or your partner have any other savings or investments?
If ‘Yes’, give details. Include details of any compensation, funeral bonds
or any other money you have not told us about.
You
.
Date you bought them
Date you bought them
Do you or your partner have any stocks and shares?
Number of shares
.
No .
Yes .
Your partner
You
Your partner
Do you or your partner own any other land or
property other than your home?
(This includes houses and time shares)
No
.
Yes
.
No
.
Yes
.
Is there a mortgage on the other property?
No
.
Yes
.
No
.
Yes
.
If ‘Yes’, how much do you owe?
£
£
What is the address of the property?
Does an elderly or disabled relative live in the property?
No
.
Yes
.
Is the property up for sale?
No
.
Yes
.
Date put up for sale
/
Evidence
You must provide proof of all bank, building society and post office accounts, savings and investments.
We need to see your savings books or last two monthly statements.
The documents must be originals.You can take them to your Local Office.
Do not send any savings books by post.
14
/
Section 12
About where you live
Only fill in this section if you are a Private tenant or Housing Association tenant.
No
12(a) Are you charged rent for your property?
.
Yes
.
If ‘Yes’ please give your landlord’s full name and address:
(your landlord is the person who owns your property)
If your landlord has an agent, please give their full name and address.
(The agent is the person or organisation you actually pay your rent to)
If you rent your home from a private landlord, the owner should
be registered with the local authority.
Please state your landlord’s Registration number (if known)
Tell us how many rooms there are in the property:
Living rooms
Bedrooms
Bedsits
Other
Bathrooms rooms
Kitchens
Total
Number of rooms in
the whole property
Number of rooms just for
you and your family
Number of rooms you
share with other people
If you are a tenant of a Housing Association, please go to section 13
.
You
Are you, your partner or your children related to
your landlord or their partner?
No .
If ‘Yes’, what is the relationship?
.
Your partner
Yes .
No .
Children
Yes .
No .
.
Yes .
.
Did you own all or part of the property you now
want to claim benefit for?
You
No
.
Yes
.
No
Your partner
Yes .
.
Have you previously lived in the property which you now
want to claim benefit for, but were not responsible for rent?
No
.
Yes
.
No
.
Yes
.
If ‘Yes’, who did you live with?
.
.
Yes
.
.
Yes
.
.
Yes
.
.
How much is your rent?
£
How often is your rent due? (for example, every week, every month, every four weeks)
.
Are you behind with your rent?
No
If ‘Yes’, by how much?
£
We may consider making your 1st rent payment to your landlord.
If this will cause a problem, please advise at Section16.
Does anyone share the rent with you and your partner?
If ‘Yes’, tell us who:
No
What is their share?
.
When is your next rent increase due?
.
Has your rent been registered as a fair rent by a Rent Officer?
If ‘Yes’, please send us the notice of registration form RO5.
No
What sort of tenancy do you have?
(for example, assured, short assured, tied)
.
.
When do you expect your tenancy to end?
Who receives the Council Tax bill for your home?
/
/
.
15
12(b) Items included in your rent
Does your rent include meals?
No .
Yes
If so which meals are provided?
Breakfast only .
At least one meal other than breakfast .
At least three meals a day
Does your rent include any of the following services? (Please tick the appropriate boxes)
Service
No
How much
each week?
Yes
Cleaning
Electricity
Gardening
Heating
Hot Water
£
£
£
£
£
Service
No
.
.
How much
each week?
Yes
Laundry
Lift Maintenance
Lighting
Personal Care and Support
Other
£
£
£
£
£
12(c) About your home
No
.
In the middle
.
Is your home a rented room or rooms?
Where in the property is your room?
At the front
.
Yes
At the back
.
.
Number of rooms in the whole building:
Number of floors in the whole building:
Which floor is your home on?
On all floors .
In the basement
On the third floor .
Other
.
.
On the ground floor .
On the first floor .
On the second floor .
.
12(d) Type of accommodation
Detached house
Terraced cottage
Hotel
Detached bungalow
Tenement flat
Board and Lodgings
Detached cottage
Villa flat
Shared room
Semi-detached house
Flat over a business
Hostel
Semi-detached bungalow
Upper flat
Site rent
Semi-detached cottage
Flat in a house
Static caravan
Terraced house
Maisonette
Other (give details)
Is the property:
fully furnished?
partly furnished?
hardly furnished?
unfurnished?
Does the property have:
central heating?
double glazing?
carpets?
a garden?
a garage?
a parking space?
Who is responsible for decorating the inside of your home?
No
No
No
No
No
No
You
Yes
Yes
Yes
Yes
Yes
Yes
.
Landlord .
Don’t know .
Evidence
You must provide proof of your rent and tenancy agreement, for example, your lease or a letter from your
landlord.This should include your landlord’s or agent’s name and full address, dates of your tenancy, how
much your rent is and how often it is due and details of what is included in your rent.
The documents must be originals.You can take them to your Local Office.
16
Section 13
For most Private tenants, we must now pay Housing Benefit direct to you, not your landlord however, this option is
still available in certain circumstances. More details regarding this are on page 2 of this form.
How you will be paid and the choices you have
• If you are a council tenant, we will pay any Housing Benefit you are awarded into your rent account;
• If you are a housing association tenant, in most cases you can choose where to have your money paid.
We will either pay it straight into your bank account or direct to your landlord;
• If you are a private tenant we will pay your money in to your bank account; by cheque or in some
cases direct to your landlord.
• If you are awarded Council Tax Rebate, we will pay this into your Council Tax account.
• Who. do you want your benefit paid
to?
.
You
.
Your agent/landlord
Directly to your Housing Association
Payment direct to a bank account
This is the safest way to pay you. If you do not have a bank account, now may be the right time to open one.
You can set up a standing order or direct debit to pay your rent to your landlord.
It will be your responsibility to ensure that payment of your rent is made to your Landlord.
Please complete for BACS payment
Bank:
Branch Address:
Account Holders
Name(s):
Account Sort Code:
Account Number:
Contact details: Telephone: 08451 551155 Email: [email protected]
Section 14
Checklist
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.You can take all documents to your Local Office
where we will copy them and return them straight away.
If you do not provide all the evidence we ask for, we may not be able to pay you any benefit.
We need the same details for your partner if you have one, and the details of any other adults living in
your home.
If you cannot send all the evidence at the moment, send the form back to us now to make sure you do not lose any
benefit and send the evidence later. We may not be able to pay you any benefit until we have all the evidence.
For details of what we will accept as evidence, please see the appropriate sections.
You only need to send evidence of the sections that you have filled in.
- Evidence of identity (section 1a)
- Evidence of NINO (section 1b)
.
.
- Evidence of other income
(section 9)
.
.
- Evidence of dependent
children (section 3)
.
- Evidence of money paid out
(section 10)
- Evidence of other people
who live with you (section 4)
.
- Evidence of savings and investments
(section 11)
.
- Evidence of earnings (section 7 and 8)
.
- Evidence of private rent and
tenancy agreement (section 12)
.
17
Section 15
Sharing information with your landlord
Sharing information with your landlord could help us deal with your claim more quickly and 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. In these circumstances, we can contact your landlord without your
permission.
The law requires that we inform your landlord of certain decisions we make on your claim, for example, when a
decision is made to pay your benefit to your landlord. Under the Data Protection Act 1998 we need your
permission to discuss anything else.
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.
If you give us permission, we would be able to tell your landlord whether:
• you have claimed Housing Benefit, or
• we have made a decision on your claim, or
• we need more information to make a decision on your claim, and what that information may be.
We will not give your landlord any information about:
• your personal or household circumstances, or
• your financial circumstances.
If you want to give us permission to share information about the progress of your Housing Benefit claim with
your landlord or their representative, please sign below
Signature
Fife Council Information in Other Languages / Alternative Formats
If you would like information from Fife Council in a language other than English, or in an alternative format such as large
print, Braille etc please cal 08451 55 55 00.
As well as arranging to provide documents in other langauges, there is a real-time interpreting service available on this
number to answer questions from speakers of other languages, or deaf customers.
18
Section 16
Anything else to tell us about
Please use this space to tell us anything else you think we should know.
Benefit Fraud
This is a criminal offence that costs the average family unnecessary taxes.You can make a difference.
Please ring the hotline on 01592 583637 to make an anonymous allegation or to report your suspicions.
19
Section 17
Form filled in by someone else
This section must be filled in if someone else has filled in the claim form for you.
This includes relatives, friends or Fife Council employees.
Name of the person who filled in the form
Signature of the person
Relationship to you
You (the person claiming) must still sign the declaration.
Appointee
By appointee we mean someone who is filling in the form for you.
If you are the appointee, please give details about yourself below.
Name:
When you act as an appointee you take over
all rights and responsibilities of the claim.
This means you must make the claim, tell us
about any changes in circumstances and repay
any overpayment of benefit where appropriate.
Address:
Phone number:
Your relationship to the person claiming:
Section 17 (continued)
Declaration
Even if someone else has filled in this form for you, you must sign the declaration, if you can.
Please read this declaration carefully before you sign and date it.
-
Fife Council may make any enquiries needed to check the information on this form.
I/We confirm that all the information on this form is a full statement of my income, savings and investments.
If I give information that is incorrect or incomplete, Fife Council may take action against me.This may include
court action.
Fife Council can use the information I have given on this form to prevent and detect fraud. Fife Council may
also share it for the same purpose, with other organisations handling public funds.
I confirm that all the details on this form are true and complete.
I will tell Fife Council immediately, in writing, about any change in my income, savings and
investments or any other circumstance which may affect my claim.
I understand that if I do not tell Fife Council about any changes, I may have to repay any overpayment of benefit, and I
may also be prosecuted, have to pay a fine, or other action may be taken against me.
Your signature:
Date:
/
/
Your partner’s
signature:
Date:
/
/
If you are claiming as a couple, you must both sign the declaration.
September 2011
20