Fillable 2018-10-22-discretionary-housing-payment-application-form-v2 Discretionary Housing Payment application form

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2018-10-22-discretionary-housing-payment-application-form-v2 Discretionary Housing Payment application form

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Revenues and Benefits Service
PO Box 490
Rochdale
OL16 9AJ
Phone: 0300 303 8870
Fax: 0845 409 5432
Website: www.rochdale.gov.uk
Email: revenues.benefits@rochdale.gov.uk
Discretionary Housing Payment (DHP)
If your Housing Benefit or Universal Credit entitlement does not pay your full rent or if you need a payment
towards housing costs, you may be able to get extra help with a Discretionary Housing Payment.
Please read these notes carefully before filling in this form.
There are some Sections on the form that you must fill in and some you can decide whether or not to fill in
(these are clearly marked on the form).
If you fill in all the Sections it will give us a much better understanding of your situation and will help us to
take into account all your circumstances when we are making our decision about your application.
If you’re not sure which Sections of the form to fill in it’s better to complete them all.
If you are receiving Universal Credit you will need to send us your latest Universal Credit award letter,
details of your bank or building society where your DHP should be paid into and proof of your rent, for
example a copy of your tenancy agreement. If we need to see proof of anything else we will contact you.
The Council is working with The Bond Board to support customers who apply for a Discretionary Housing
Payment. The Bond Board is a charitable organisation that helps people to get a home or to keep their
current home. We would like to share the information you provide with them so they can give you
personal advice and support, if you don’t want us to do this you can tell us at the end of the form.
If you have any questions please contact one of our customer services advisors. You can do this:
• By email, to revenues.benefits@rochdale.gov.uk.
• In writing, to PO Box 490, Rochdale, OL16 9AJ.
• By phone, on 0300 303 8870.
Discretionary Housing Payment (DHP) Application Form
Benefit Claim Number:
Council Tax Reference:
Name:
Phone Number:
Email Address:
You don’t have to give us your phone number or
email address but it may help us if we need to
contact you and could mean that we can make a
decision on your application more quickly.
Address:
Please tell us why you want a Discretionary Housing Payment:
Help with removal costs, rent in advance or a bond.
Help with rent arrears so you can move.
Help to pay your rent
Section 1 – this is about you and your home and you must fill this in.
What is your date of birth:
If anyone else lives in your home please tell us:
Their name Their date of birth
Their relationship to
you
Is your home:
Rented from a housing association
Temporary Housing
Rented from a private landlord
Supported Housing
How many bedrooms are there in your home?
Please tell us your landlords:
Full name:
Address and postcode:
Phone number:
Do you receive any help or support from anyone for example a social worker?
No
Yes
please tell us their:
Full name:
Address and post code:
Phone number:
Email address:
Section 2 – this is about your circumstances and you must fill this in.
Do you have shared custody of any children who stay overnight with you?
No
Yes
Please tell us:
Their names Their main address
How often do they stay with you?
Section 3 – this is about any illnesses (including any mental health issues) and, or,
disabilities. You don’t have to fill this in but it would help us to make a decision if you do.
Do you or does anyone who lives with you have any health issues?
No
Yes, I have health issues
Please tell us about your illness:
Yes, someone who lives with me has health
issues
Please tell us:
Their name:
About their illness:
Are you, or is anyone who lives with you disabled?
No
Yes, I am disabled
Please tell us the nature of your disability:
Yes, someone who lives with me is disabled Please tell us:
Their name:
The nature of their disability:
Has your home been adapted to meet the needs of the person with a disability?
No
Yes
Please tell us what adaptations have been made:
Does anyone provide you with care and support? No Yes
Please tell us:
Their name:
Their address:
Do they need to stay overnight? No Yes
Do you care for someone who lives close by? No Yes
Please tell us:
Their name:
Their address:
Section 4 – this is about moving house and you must fill this in.
Are you registered for rehousing with a landlord or
with any letting agencies?
No Yes
Please tell us:
How long have your been registered with them?
What are the addresses of any properties you have applied for?
If you are not moving please go to Section 5.
Why you are moving:
Where you are moving to:
What costs do you need help
with:
How many bedrooms are there in
the house you want to move to?
Please tell us the name, address and phone number of the landlord at the house you want to move to:
Full name:
Address:
Phone number:
Section 5 – this is about paying your rent, rent arrears and any other debt, you must fill
this in.
Do you have any rent arrears? No Yes Please tell us:
How much are your rent arrears?
Why do you have the rent arrears?
Are you at risk of losing your home because of your rent arrears? No Yes
Why do you need help to pay your rent arrears?
Do you have any other debts? No Yes Please tell us:
What the debt is How much you owe
Why do you have these debts?
You need to send us proof of any rent arrears or any other debts for example an arrears statement.
If you don’t have this to hand don’t delay sending this form to us, you can send us the proof later.
Section 6 – this is about your application, you don’t have to fill this in but it would help us
to make a decision if you do
Are any organisations helping you with budgeting or debt
advice?
No Yes Please tell us
Who is helping you?
What action have you taken to sort out your money issues?
How long do you think you will need a DHP for before you can manage on your own without any help?
What have you done to reduce your household costs?
Is anything stopping you from finding work or increasing the numbers of hours you work?
What have you done to try and find work or increase the number of hours you work?
Section 7 – Income and Expenses, you must fill this in.
Income
Amounts you get
Expenses
Amounts you spend
Weekly
Monthly
Weekly
Monthly
Take home wages or
salary
Rent – this is the
amount your landlord
charges you
Partner’s take home
wages or salary
Council Tax
Life insurance
Work pension
Water
Income Support or
Jobseekers Allowance
House insurance
Employment and
Support Allowance
Gas
Electricity
Universal credit
Clothing and shoes
Child Benefit
Housekeeping (food,
toiletries and so on)
Child Tax Credits
Working Tax Credits
TV package (for
example Sky, Virgin)
Personal
Independence
Payments
TV licence
Internet
Disability Living
Allowance
Phone
Car expenses
Attendance Allowance
Bus or taxi fares
Other state benefits –
please give details
Meals at work
School meals
Maintenance
Child care costs
Money from other
people who live with
Maintenance payments
Other - please explain
Other - please explain
Total income
Total expenses
Savings – (You and your
partner, if applicable)
Account
balances
Debts
Amount still
owed
Payments
Week
Mon
Bank account
Rent arrears
Savings account
Other:
Building society
Post office
Other - please explain
Total savings
Total debts
If you are receiving Universal Credit: You will need to send us your latest Universal Credit award letter,
details of your bank or building society where your DHP should be paid into and proof of your rent, for
example a copy of your tenancy agreement.
Section 8 – Declaration, you must fill this in.
The information I have given on this form is true and accurate. I will tell your Benefits Team if
there is any change in circumstance in my home. I understand that you might check the
information I have given.
To help with m
y application I give permission for the Council to share my information with The
Bond Board or other agencies. The Bond Board helps people to get a home or keep their current
home.
Yes
No
Your signature:
Date:
Return the f
orm and any evidence to any Customer Service Centres at:
• Number One Riverside, Smith Street, Rochdale OL16 1XU.
• Middleton Library, Long Street, Middleton M24 6DU.
• Heywood Library, Lance Corporal Stephen Shaw MC Way, Heywood OL10 1LL.
• Revenues and Benefits Service, PO Box 490, Rochdale OL16 9AJ.
If you are renting your home from a Housing Association you can also take it to them and they will send it
to us.
You can find
out how we use your personal information at rochdale.gov.uk/privacy
.
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Completed 5 July 2020

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