Housing Benet and Local Council Tax Reduction
Change of Address Form
Date moved out
New address
Date moved in
Claimants
signature
Date
I herby con rm there has been no other changes in either my circumstances or in the circumstances of anyone who
lives in the property with me as part of my household that I have not already reported in writing to the Bene t Service.
Where this change of address has given rise to a Council Tax liability, I wish to be considered for Local Council Tax
Reduction based upon the circumstances already held by the Bene t Service.
Telephone number
Part 1
Claim Reference
Full name
Previous address
Cannock Chase Council
tel 01543 464292 | web www.cannockchasedc.gov.uk | www.cannockchasedc.gov.uk/benefitform
s
Printed name
To nd out more about Housing Benet and Council Tax Reduction call or visit our website
Stafford Borough Council
tel 01785 619478 | web www.staffordbc.gov.uk | www.staffordbc.gov.uk/benefitforms
This form should be completed where the only change in circumstance is a change of address.
Postcode:
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Postcode:
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No Yes Please go to Part 3
No Yes Answer the next question
No Yes Tell us the details below.
Are you a council tenant? No read questions below Yes There is no need to answer any further questions
What sort of building do you live in? Tick one box only
Detached house Flat in a house Caravan, mobile home or houseboat
Semi-detached house
Flat in a block Board and lodgings
Terraced house
Flat over a shop Hotel
Maisonette Bedsit or rooms or a studio fl at Residential nursing home
Detached bungalow
Hostel Residential care home
Semi-detached bungalow Other
Does your home have central heating? No Yes
Does your home have a garden? No Yes
Does your home have a garage? No Yes
Does your home have a parking space? No Y
es
Do you and your household live in No Y
es
only part of the building you have ticked?
How many fl oors are there in the whole building?
Which fl oors do you live on? F
or example, ground fl oor or fi rst
oor
Where in the building do you live?
At the front
At the middle
At the back
2
Tell us about your new address
Do you own your home?
Part 2 - About Rent
Do you pay rent for your home?
Tick ‘Yes’ if you would pay rent but you
already get Housing Benefi t
(including Local Housing Allowance).
Does anyone else share the rent with
you and your partner?
Tell us their names and their relationship to you
and your partne
r.
How much of the rent do they pay and how often?
(For example, every week, every two weeks,
every four weeks or every month.)
£
every
What is your landlord’s full name
and business address?
By landlord we mean the person
or organisation who owns the
property you live in
Phone number
Are you, your partner or any of your or No Yes What is their relationship?
your partner’s children related to your
landlord or agent, or to your landlord’s
partner or the agent’s partner?
Related includes related through marriage,
even if the marriage has ended. Some
examples are ex-wife, ex-husband, aunt,
brother, daughter, father, grandson,
grandmother, son-in-law or stepdaughter.
When did you start renting your home?
When did you move to this address?
If you have not moved in yet, tell us when
you expect to move in. When you move in,
tell us the date you moved in.
What sort of tenancy do you have?
(F
or example, shorthold, assured tied rent
or something like this.)
How long is the tenancy for?
to
What is the property let as? Furnished Barely furnished
Tick the box that applies. Partly furnished Unfurnished
No Yes
How much rent do you pay and how often?
(For example, every week, every two weeks,
every four weeks or every month.)
Has your rent changed in the last 12 months?
When is the next rent increase due?
Send us proof of the date it changed and how much it changed.
Is the landlord or agent’s
3
We must see proof of your rent and tenancy before we can decide how much benefi t you can get.
we can accept as proof of your rent a tenancy agreement or letter from your landlord.
How many rooms are there? In the Just for you and That you share with
whole building your household other people
Living rooms
Bedsit
Bedrooms
Bathrooms or shower rooms
Toilets
Kitchens
Other rooms
/ /
/ /
/ /
/ /
£
every
/ /
Has your rent been registered as a fair rent by The Rent Service? No Yes
Do you have any weeks when you do not have rent to pay rent? No
Are you behind with the rent?
Who pays the council tax bill for your home?
Tick the box that applies.
What is the council tax reference number?
Does your rent include the following?
Meals No
Yes How much?
For which meals?
Please tick
Evening meal Lunch
Water authority charges No
Yes
Heating No
Yes How much?
Lighting No
Yes How much?
Hot water No
Yes How much?
Fuel for cooking No
Yes How much?
Laundry No
Yes How much?
Cleaning rooms or windows No
Yes How much?
Gardening No
Yes How much?
Garage or parking space No
Yes How much?
Do you have to rent the garage as part of your tenancy agreement? No
Yes
Personal care and support No
Yes How much?
Do you pay any service charges separate from No
Yes
How much?
your rent (for example, for cleaning or lighting in
shared areas, an alarm system, a warden, general
counselling or support, a warden, meals or lift
maintenance)?
No
Yes
Please send us the notice
of registration from RO5.
How many in a year?
You or your partner Your landlord
Someone else Tell us who it is
What for?
4
Yes
By how many weeks?
£
every
Breakfast
How much?
£
every
£
every
£
every
£
every
£
every
£
every
£
every
£
every
£
every
£
every
£
every
Are you living away from home at the moment? No
Yes
Tell us about it below.
Why are you not living at home?
When did you last live at home?
When do you expect to go back home?
What is the address of where you are living
at the moment?
No Yes Who lives there now?
Sort code
Account name
Bank account number
No Yes
No Yes Tell us about it below
Have you sublet
your home?
Do you use your home for business?
Do you have a mai
n home somewhere else?
If your main home is somewhere else in
the UK or abroad, tick ‘
Y
es’, even if you
do not pay rent for it.
What is the address?
P
ayment Details (HB ONL
Y)
If you want to have the bene
t paid directly
to you please con rm your sort code, bank
account number and the name the account
is in
If you want to have the benefit paid to
your landlord or a third party, please tell us
why this is
Part 3
How we use
your personal inf
ormation
We will use the information you provide to process your Housing Benefit and/or Council Tax Reduction claim. We will only share your information, when
necessary, with agencies involved in the processing of
benefits or where the law requires or allows us to.
Cannock Chase District Council is the Dat
a Controller for any claims or information submitted by residen
ts of the Cannock Chase area, for further
information, please see
www.cannockchasedc.gov.uk/PrivacyNotice.
Stafford Borough Council is the Data Controller for any
claims or information submitted by residents of the
Stafford area, for furt
her information,
please
see
www.staffordbc.gov.uk/PrivacyNotice.
This form can be provided in Braille, on audio cassett
e tape/disk, LARGE PRINT and in ot
her
languages on request to
Stafford Borough Council
Cannock Chase Council
tel 01785 619478
tel 01543 462621
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