This information can be made available in large print, braille, audio/CD or in another language upon
Please telephone: 01323 443500 Email: firstname.lastname@example.org
Please read this declaration carefully.
• As far as I know, the information I have given on this form is correct and complete
• You may make any necessary enquiries to check the information on this form
• You may cross check the information I have given with other services in the council, other council
or benefit authorities, including HMRC.
• I understand that if I give information that is incorrect or incomplete or fail to report any changes
which might affect my benefit, I may be prosecuted.
We will keep this information confidential, but if you fall behind with your rent or council tax
payments, our Recovery Officers may need to read this form so that he or she can help you.