Nov 16
Application for a Discretionary
Housing Payment (DHP)
Revenues & Benefits Service, PO Box 410, Stockton-on-Tees, TS23 2YD
Helpline 01642 393829Minicom 01642 605569
Claim number
1. Your Details
Main phone no.
Alternative phone no.
E-mail address
Amount of any rent arrears
Have you been served with a notice to
Yes Call Housing Options on 528389 to apply.
How long do you need help (DHP) for?
If help is needed for less than a year please tell us the reason for this
2. Reason applying for a DHP
Tick all relevant boxes
I have too many bedrooms for my needs
Myself or a member of my family is an approved foster carer
My home has been significantly adapted for a member of the family
who is disabled or suffering from health problems?
My weekly benefit has been restricted to £384.62/£257.69 a week
Financial reasons
Health reasons
Other please state -
3. Foster Carers
Are you or a member of your family an
approved foster carer?
Yes Answer the questions in this section and go to
the declaration at the end of the form.
Who are you registered with as a foster carer?
Name of Agency
Name of Social Worker
Telephone Number
Please enclose any supporting evidence when you return this form.
4. Temporary Absence
Is someone who usually lives with you a member of the
armed forces on operations, or temporarily absent from
the home such as a son or daughter at university?
If yes, give details
5. Bereavement
Have you had a bereavement within the last 12 months
of a member of your family who lived with you?
No Go to part 6
Yes Answer the questions below
Name of the person
Relationship to you
Date of death
6. Medical Problems
Do you or a member of your family have a disability or
any health problems?
No Go to part 7
Yes Answer the questions below
If yes, give details of any disability or health problems in the space below.
Enclose any supporting evidence that you already have when you return this form, such as a copy
of a care plan, occupational therapist or doctor’s letter, hospital or clinic appointment card or
medical certificates.
Is a bedroom used by a carer who does not live in your home to
provide overnight care?
No Yes
If yes, tell us who the care is needed for, who provides the care and how often the overnight care
is provided.
Has the property been significantly adapted for a member of the
family who is disabled or suffering from health problems?
No Yes
If yes, please give details
Does this disability or health problem mean you need more bedrooms
than you are allowed under the benefit rules?
For example this might be because a disabled person is unable to
share with someone else because of the disability, or a room may be
used to store equipment or used for treatment.
No Yes
If yes, please give details.
Does this disability or health problem mean that there are additional
costs to be met, such as costs for medicines, transport for treatment,
or child care?
No Yes
If yes, please give details.
7. Finances
Please provide as much detail as possible of your weekly income and outgoings.
Income Support
Full Rent due
Jobseekers Allowance
Water Rates
Employment and Support Allowance
Council Tax
Universal Credit
Child Benefit
Household items
Baby items, nappies, etc
State Retirement Pension
Clothes, shoes, etc
Works Pension
Pension Credits
Mobile Telephone
T.V. License
Credit Card Payments
Child Tax Credit
Working Tax Credit
Home Insurance
Life Insurance
Personal Independence Payment
Bus Fares
D.L.A (Mobility)
Prescription Charges
D.L.A (Care)
Medical Items
Attendance Allowance
Car Expenses (Tax, Insurance etc.)
Housing Benefit
Social Fund Loan outstanding £
Local Council Tax Support
Crisis Loan outstanding £
Other Loans outstanding £
Other Benefits/Income
Fines - outstanding £
School Meals
Savings/Capital Held
Bank/Building Society accounts
Pocket money
Other Outgoings (Specify)
Other (Specify)
If your weekly outgoings are higher than your weekly income please explain below how you are
meeting your outgoings.
Does anyone living in your home other than your partner contribute to
housing costs?
No Yes
If yes, give details of how much they currently contribute and if this can be increased?
If no, please explain why no contributions are currently being made or they cannot be increased.
Have you taken any steps to improve your money problems yourself?
No Yes
If yes, please give details.
Please give details of any other relevant financial issues.
8. Private Tenants
Do you rent your home from a private landlord?
No Go to part 9
Yes Answer the questions below
Why did you choose to move to this property?
Tell us if you had to move quickly because you were fleeing violence, or of any reasons why you
need to live in this location.
Were you able to afford the rent when you moved in?
If no, give details of;
No Yes
why you took on the tenancy if you could not afford it,
any housing benefit advice you sought before taking on the property, and
any other properties you considered before moving in.
If yes, explain the reason you are now unable to afford the rent?
Have you asked your landlord to reduce the rent charged?
No Yes
If yes, give details
9. Alternative Accommodation?
Have you taken any action to find smaller or cheaper accommodation or
do you have any plans to do so?
No Yes
If yes, give details, such as registering with other landlords for accommodation or requesting a
transfer to another property with the same landlord.
Would you or any other people living with you have difficulty moving home?
No Yes
If yes, give details.
10. Other Details
Is there anything else you would like us to know?
11. Help and Advice
The Council only has a limited amount of money available to spend on Discretionary Housing
Payments and will not be able to help everyone who asks. We try to target the funds so that the
most vulnerable people are helped. Any help given will normally be for a limited period.
Advice agencies such as Stockton and District Advice and Information Service, and Stockton
Welfare Rights can help with longer term solutions, providing help and advice on;
claiming welfare benefits
dealing with outstanding debts, or
budgeting and managing your finances,
Would you like to be referred to an appropriate advice
No Yes
I agree that the advice agency I am referred to can feedback the outcome of this referral to
Stockton-on-Tees Borough Council.
If you do not want to be referred to an advice agency please give reasons
I have read or had read to me the above information and agree that it is correct.
I give authority for Stockton Benefits Service to confirm any information given on this form with the
Department for Work and Pensions, my landlord/landlady or any other department of the Council.
I understand that the information I have given may be shared with Stockton’s Housing Options Team.
This authority also includes the release of any information regarding Back on Track (social fund
replacement) loans.