Application for Discretionary Housing Payment/Council
Tax Discretionary Relief
Name & Address:
Email Address and Contact Number:
Date of Issue:
Council Tax Account Number:
Housing Benefit Claim Reference:
Discretionary Housing Payment and Council Tax Discretionary Relief
Discretionary Housing Payments (DHP) are designed to provide short-term financial support to
customers who are already getting Housing Benefit (or an element of housing costs within their
Universal Credit) who need extra help with their rent.
The DHP fund is limited so we will not always be able to help you.
In order to apply for discretionary housing payments you must:
Be entitled to Housing Benefit or receive housing costs within your universal credit and
Have a liability to pay rent and
Demonstrate that you require further assistance in order to meet your housing costs
(please note: we cannot pay a DHP to help with water rates, service charges or for things
like heating and lighting)
Council Tax Discretionary Relief is intended for customers who are suffering from hardship due
to exceptional circumstances who require help to meet their Council Tax liability. It is only used
for short term assistance.
In order to apply for Council Tax discretionary relief you must:
Be the person responsible for paying the Council Tax and
Demonstrate that you need financial help in order to pay your Council Tax
I am applying for (tick one only): Discretionary housing payment……….
Council Tax discretionary relief……….
Both……………………………………
Please complete this form and provide all the evidence that has been
requested in support of your application. Without the information there may be a
delay in our decision because we may have to write to you.
Please complete all sections of this form
Please state why you need additional support with your housing costs (including your Council Tax):
This could be:
To pay rent arrears (you must provide evidence of your arrears).
To help you for a short period in the past due to your circumstances at that time (you need to
explain why you did not apply at that time).
For a short period to help you until your circumstances improve (you need to explain what
changes you are expecting in your circumstances and how long you think you will
need help for).
To help you to move home e.g. help with removal costs, rent deposit or rent in advance (only
where you are moving from an unaffordable, unsustainable tenancy to an affordable
property where you can pay the rent without needing a DHP)
Please give full details of why you need the additional financial help, and what effects a shortfall in
funds to meet your housing costs will have on you and your family
Please say what steps you are taking to improve your circumstances so that a long-term discretionary
award is not needed.
Section 1: Reasons for your application
I am applying for additional support because…………..
Please provide your details and those of your partner (if you have one) below:
Date of Birth
NINO
Male/Female
Disabled
Please state if you are:
Sole occupier under 35 years old… Sole occupier over 35 years old… A lone parent…
A couple, under retirement age… A couple, over retirement age…
An expectant mother… Date your baby is due ___/___/___
How many dependent children do you have living with you (under 18 or 18-20 in full-time education
for whom you receive child benefit) ______.
Please give their details below (Please use a separate page if you have more than six children):
Date of
Birth
Male
Yes/No
Female
Yes/No
Shares a
bedroom
Yes/No
Disabled
Yes/No
Please list all adults in your household (anyone for whom you do not receive child benefit)
Date of Birth
Male/Female
Income
Please state amount
received
Disabled
Yes/no
Is anyone who normally lives in your household a member of the UK armed forces: Yes… No…
Please provide details below:
Full Name
Date of Birth
Male
Female
Is anyone who normally lives in your household is away studying at university Yes… No…
Please provide details below:
Full Name
Date of Birth
Male/Female
University
Course start
date
Course
end date
Section 2: About your household
Council Tax
Do you have arrears of Council Tax? Yes… No… If yes, how much do you owe? £________
Have you tried to make an arrangement to pay these arrears? Yes… No…
If your answer is No, please explain why you have not tried to resolve your situation prior to your
application?
Mortgage
Do you pay a mortgage? Yes….. No……
Are you up to date with your mortgage payments? Yes….. No……
If your answer is no, how much do you owe? £_________ (You must provide proof of any arrears)
Rent
Do you pay rent for your home? Yes… No… Who do you pay? _____________________
Were you able to afford the rent when you moved in? Yes… No…
If yes, please explain what has changed:
Please state the date you moved to this address: ___/___/_____
If this is within the last 12 months, please explain why you moved to this address
Do you have rent arrears? Yes… No…
If your answer is yes, how much are your arrears? £________. You must provide proof of these
arrears (this should be a letter from your landlord and/or your latest rent statement showing the
arrears), if you do not have any arrears, please explain how you have paid the shortfall in your rent?
Have you asked your landlord if he/she would accept less rent? Yes… No…
If your answer is yes, what was the outcome?
Has your landlord/lady asked you to leave the property? Yes… No…
If your answer is yes, on what date have they asked you to leave? ___/___/_____
If you have received a written notice from your landlord asking you to leave your property
please provide this.
Section 3: About your accommodation and your housing costs
Foster carers
Are you a registered foster carer who needs additional bedrooms? Yes… No…
Are you currently fostering and have a child or children in your property? Yes… No…
If your answer is no, please confirm the date of your last placement ___/___/______
Adapted property
Has your property been adapted for your or your household’s disability needs? Yes… No…
If your answer is yes, please give full details of the adaptations:
Proof will be needed this should be a letter from your landlord explaining what adaptations
have been made to your home.
Alternative accommodation
If you are a Council or Housing Association tenant, and are living in a property which is too large for
your needs, please state if you have applied to transfer to a smaller property? Yes No…
If your answer is yes, please give details
If your answer is no, please explain why you have not asked to downsize?
Have you refused any properties that have been offered to you? Yes… No….
If your answer is yes, please provide full details
If you are a private tenant, have you tried to find cheaper accommodation? Yes….. No….
If your answer is yes, what steps have you taken?
If your answer is no, please say why not?
Are you registered with Barnet Homes Housing Options service? Yes… No…..
If your answer is yes, what have they advised you to do?
If you have registered with Barnet Homes, are you actively bidding on alternative properties?
Yes…. No….
Section 3: About your accommodation and your housing costs (continued)
Can you move to a more affordable property? Yes… No….
If your answer is no, please explain why you cannot move
Do you need to live in the Borough of Barnet? Yes…. No….
If your answer is yes, please say why?
If you need help with removal expenses, a deposit or rent in advance for a new property, please say
why you are moving, how much your moving expenses, deposit and/or rent in advance will be and
confirm how much rent you will be charged at your new address.
Please note:
You will need to provide confirmation of the above, such as estimates for removal expenses,
and a letter from your prospective landlord confirming the amounts concerned before you
commit to your new tenancy.
Your request will only be considered if you are moving from an unaffordable, unsustainable
tenancy to an affordable property where you can pay the rent without needing a Discretionary
Housing Payment (DHP).
Section 3: About your accommodation and your housing costs (continued)
INCOME
How
much
(£)
How
often
OUTGOINGS
How
much
(£)
How
often
Office
use
only
Net wages
(For you)
Mortgage / Rent *
Net wages
(For your partner)
Rent arrears*
Self-employed earnings
Council Tax
Working Tax Credit
Council Tax arrears*
Child Tax Credit
Electricity *
Child Benefit
Gas*
JSA (Conts)
Arrears of fuel bills*
JSA (IB)
Water rates
Income Support
Child minding *
Pension credit
(guarantee)
Food
Pension credit
(savings)
School meals
State retirement pension
Housekeeping
Occupational / private
pension
Clothing
Maintenance received
(for children)
Laundry
Maintenance received
(for self or partner)
Telephone / internet
Incapacity Benefit
TV licence / rental
Employment and
Support Allowance
Satellite / Cable TV
Disability Living
Allowance
Travelling expenses *
Personal Independence
Payment
Road tax / car insurance
Carers Allowance
Oil / petrol / Servicing *
Housing Benefit
Court fines*
Universal Credit
Prescriptions
Contributions from
children living at home
Maintenance paid *
Contributions from any
other residents
Credit card *
Any other income
Loans / hire purchase *
Vouchers or tokens in
lieu of payment
Deductions for social fund *
Other deduction from benefit *
Catalogue
Cigarettes / Alcohol
Endowment / Life Assurance *
Mortgage Protection *
Home insurance *
Medical / disability related
outgoings (please specify)
Any other outgoings
TOTAL INCOME
TOTAL OUTGOINGS
Section 4: About your household income and outgoings - Please note: You MUST
supply supporting evidence for any items marked with a * and your last 2 months
bank statements
Do you run a car? Yes… No….
If your answer is yes, please explain why you need a car
Please confirm if you have any other debts outstanding? Yes… . No….
If your answer is yes, please provide full details and proof
Have you sought any advice on how to deal with these debts? Yes…. No….
If your answer is yes, please explain what advice was given to you
Section 4: About your household income and outgoings (continued)
Please read this declaration carefully before you sign and date it.
I agree that you will use the information I have previously given on benefit applications or
Council Tax reduction applications to consider my request for discretionary housing
payments/discretionary Council Tax relief. You may share the information I have given
with other sources as allowed by the law.
I declare that the information I have given on this form is correct and complete as far as I
know
I authorise you to check the information I have given with other sections within the
Council, the VOA, other Councils or Authorities handling public funds, as long as you do
so only to prevent and detect fraud and error.
I understand that you will share the information you hold to prevent errors and detect
fraud by providing information to the Housing Benefit Matching Services and the Audit
Commission’s National Fraud Initiative.
I understand that if I give incorrect or incomplete information or documents, or fail to
report any changes that might affect my benefit, I may be prosecuted.
I know I must tell you immediately of any changes that may affect the amount of benefit I
receive and that I cannot rely on any other organisation or person to tell the Council on
my behalf.
I agree to notify the Council immediately of any changes in my circumstances which may
affect the amount of discount that I receive; e.g. changes in the amount of any benefits
or allowances that I receive, changes to the number of people who live with me, children
leaving full-time education or any other matter that is covered in this application
I also agree that the DWP or Job Centre Plus may provide the Council with information
about any benefits that I receive where it is relevant to this claim.
I fully understand that if I do not notify Barnet Council’s revenues and benefits service of
any change to my income or household circumstances at the time of the change, my
discretionary relief/discretionary housing payment will be adjusted from the date that the
change happened and I will have to repay any discretionary payment that I was not
entitled to.
I accept that you may prosecute any person who gives incorrect, incomplete or
misleading information to fraudulently claim benefit.
The information you have given us will be used to manage your benefit claim and will be
shared with other central or local government bodies in line with the council’s registration
under the Data Protection Act 1998 (For details on how the council will use your information please
see our privacy notice: www.barnet.gov.uk/info/930185/privacy/240/privacy)
Customer’s signature ………………………..........………..............................………
Date………………………………………………….
If this form has been filled in by someone other than the person claiming, please tell us
why you are filling in this form for the person claiming and sign the declaration below.
I declare that, as far as possible, I have confirmed with the person claiming that the answers
I have written on this form are correct.
Full name …………………………… Relationship to customer……………………………..
Signature …………………………… Date……………………………………
Section 5: Declaration
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