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Application for direct payments
of Local Housing Allowance
to your landlord
Benefits, 16 Church Road, Stockton-on-Tees, TS18 1TX
Helpline 01642 393829iMinicom 01642 605569
Housing Benefit
Claim Number
What is this form for?
We have to make all payments of Local Housing Allowance to the tenant. However we can, in certain
circumstances, make payments to the landlord.
The information you provide in this form will help us to decide whether it is appropriate to pay
directly to the landlord. You may not need to complete all the questions but try to give as much
information and evidence as possible. If you need help please get in touch with us
Where possible the tenant should complete this form but it can also be completed on their behalf. The
tenant should always sign the form and be fully aware that it may lead to their benefit being paid
directly to the landlord to cover the rent. If the tenant has not signed the form, the reasons why must
be provided in the declaration part of this form. Written evidence needs to be provided to support the
information given in this form. This can be from various sources depending on a person’s
circumstances. For example:
o Advice Workers
o Care Workers / Social Workers
o Department for Works & Pensions (DWP), Job Centre Plus, Pension Service
o Doctor / Hospital
o Courts
o Probation Officer
o The tenants family and friends
o Landlord and Letting Agencies
o Evidence from other sources may be accepted
Name of tenant:
Address of tenant.
Person completing the form (if not the tenant).
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Contact address and telephone number (if not the tenant).
If the tenant is not completing the form, please tell us your relationship to the tenant and
reason for completing the form on their behalf.
Tell us about any learning disabilities that may cause you problems in paying your rent.
Tell us about any physical disabilities or medical conditions that may cause you problems in
paying your rent.
Tell us about any mental health problems that may cause you problems in paying your rent.
Are you dealing with an addiction (e.g. alcoholism, substance misuse, gambling) that may
cause you problems in paying your rent?
Are you having problems paying your rent because you need assistance understanding
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Do you currently have rent arrears? Yes No
If yes: How much are your rent arrears?
What period do they cover?
Please provide proof of rent arrears
Has your landlord taken any action to recover your rent arrears? (court action, notice of
seeking possession, notice to quit, sent you a letter or set up a payment plan?)
If so, please tell us what and send us proof of any action taken.
Do you have debt problems- for example county court judgements or bankruptcy which you
think will make it difficult for you to budget to pay your rent? Please tell us details.
Do you receive support from any agency, organisation, friend or family member to help you to
make rent payments? Yes No If Yes, tell us how.
Are you having deductions made from your Income Support or Job Seekers Allowance?
Yes No If Yes, what is it for. We need to see proof.
Have you had any previous problems paying your rent? If yes, please give details.
Please tell us anything that means you need additional support that may cause you problems
in paying your rent? For example, if you are receiving help because of homelessness or
leaving local authority care.
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How we collect and use information.
This authority is under a duty to protect the public funds it administers. We may check
information by a third party, with other information we hold, to check the accuracy of
information, to prevent or detect crime; and to protect public funds in other ways, as permitted
by law. We may also share this information with other council departments or bodies
administering public funds for these purposes. We may also use this information to put you in
touch with our services that may be able to help you.
We will not disclose information about you to anyone, unless the law permits us to.
Person completing the form, if not the tenant
The information is true and correct
I believe it to be in the best interest of the tenant to pay Local Housing Allowance to
their landlord
I have read and understand the declaration. Please sign and date the form below
Name Signature Date
Tenants Declaration
The information in this form is true and correct
I am happy for my Local Housing Allowance to be paid directly to my landlord
I will contact the Benefits Service if I feel able to receive my benefit myself
I have read and understand the declaration. Please sign and date the form below
Please remember to include evidence to support your request
Please use this space for any additional information.
If you are having problems managing your financial affairs and would like to seek help and
advice, we can forward your details to the Stockton & District Advice & Information Service
(CAB) who will contact you.
Yes, I would like the Stockton & District Advice & Information Service to contact me
Name …………………………………………………………………..
Address ………………………………………………………………………………………………….
Telephone contact number …………………… Preferred contact time ………………………
I agree that Stockton & District Advice & Information Service can feedback the outcome of
this referral to the council.
FOR OFFICE USE ONLY Details forwarded to SDAIS …………………………..