Council Tax Support Claim Form
Don’t delay - claim today!
Please return this form as quickly as possible, even if you do not have everything we ask for, to make sure that
you do not lose any reduction.
You can send the rest to us later.
Filling in the form
· Answer ‘Yes’ or ‘No’ questions by ticking the relevant box. If you are picking an answer from a list of
answers, put a tick in the relevant box. If you do not answer a question we will have to send the form
back, and this will delay the claim.
· If someone else fills in the form for you, there is a declaration for them to sign in Part 14. You must sign
Part 14 as well.
· Your award will normally start from the Monday after we receive the form. In the form, we ask for proof
of your income and capital. If you don’t yet have all the proof we need, send the form in now and send
the proof later.
You have one month from the date we receive the form to send in the proof.
· You must tell us immediately if your circumstances change. See page 2 for a list of changes that may
affect your claim.
How to contact us in writing:
· Benefit Section, Dacorum Borough Council, The Forum, Marlowes, Hemel Hempstead, Herts, HP1 1DN
· Monday to Thursday 8.45am 5.15pm, Friday 8.45am 4.45pm.
Phone:01442 228000 and ask for “Benefits”
Email: benefits@dacorum.gov.uk
For office use only
Date of issue
Issued by
Date Received
Notes for filling in the claim form
About this form
This Council Tax Support claim form has been specially designed to be easy to fill in. It is long,
but we have to ask a lot of questions to make sure that everyone who claims gets the right amount of
reduction. You may not have to fill in all parts of the form, but you must fill in any part that is relevant to you.
Every part starts with a question to help you decide if you need to fill in that part.
Second Adult Rebate
Second Adult Rebate is Council Tax Support you can get if you are a pensioner, share your home with
someone who is not your partner, is on a low income, is 18 or over, and does not pay you rent.
If you are claiming Second Adult Rebate, only fill in Parts 1, 3, 12, 13 and 14.
Evidence
We need to see evidence of some of the things you tell us about. The checklist at the end of the form will
help you. If you are not sure if we need to see evidence of something, get in touch with us. We will tell you
what we need to see. We cannot award your reduction until we have seen the evidence we have asked for.
How we collect and use information
We will use the information you give in this form, and in any supporting evidence you send us, to process
your claim for Council Tax Support.
We may pass the information to other agencies or organisations such as the Department for Work and
Pensions and HM Revenue and Customs, as allowed by law. We may check information you have provided,
or information about you that someone else has provided, with other information we hold. We may also get
information about you from certain third parties, or give them information, to:
• make sure the information is accurate; and
• prevent or detect crime; and
• protect public funds.
These third parties include government departments, local authorities and private-sector companies such as
banks and organisations that may lend you money.
We will not give information about you to anyone else, or use information about you for other purposes,
unless the law allows us to.
The Council is the data controller for the purposes of General Data Protection Regulations/ UK Data Protection
Bill. If you want to know more about what information we have about you, or the way we use it, please visit
www.dacorum.gov.uk/privacypolicies
Changes you must tell us about Tell the Council's Benefit Department straight away if;
• any of your children leave school or leave home; or
• anyone moves in or out of your home (including lodgers, joint tenants and subtenants); or
• your income or the income of anyone living with you, including benefits, changes; or
• your capital, savings or investments change; or
• you or anyone living with you becomes a student; goes on a Youth Training Scheme; goes into hospital or a
nursing home; goes into prison; or gets, changes or leaves a job; or
• you or your partner are going to be away from home for more than a month; or
• you receive any decision from the Home Office; or
• anything you have told us about changes; or
• you move house; or
• you or any one in your household receives or ceases to receive DLA or PIP.
If you don’t tell us about these changes, you may lose a reduction you are entitled to or you may receive too
much reduction and have to pay the Council Tax back.
You must make sure that you tell us about these changes. Don’t rely on someone else to pass on the message.
It is an offence not to tell us about any change of circumstance that affects your award. We may take
court action against you. If we pay you too much support, in most cases, you will have to pay it back.
page 2
page 3
Part 1 About you and your partner
Do you have a partner who
normally lives with you?
A partner means a person you
No
are married to or have a civil
partnership with, or a person you
Yes
live with as if you were their
husband, wife or civil partner.
(A civil partnership is a formal
arrangement that gives same sex
partners the same legal status as
a married couple.) Even if your
partner only comes home at
weekends, or part of the week,
you must include them
Surname or family name
First name(s)
Any other surnames or family
names you have used, such as
before marriage or in a
previous marriage
Title (Mr, Mrs, Ms and so on)
Address
Do not tell us your partners
address if it is the same as yours.
Postcode
If you have a partner, you must answer all the questions about
them, as well as yourself.
You Your partner
Postcode
What date did you move in to
this address? (first spent the
night there)
Your daytime phone number
You do not have to tell us this,
but it may help us to deal with
your claim more quickly.
What is this number?
Please tick.
E-mail address
We want to deal with your claim
as quickly as we can and if we
have your e-mail address we may
contact you this way.
Date of birth
National Insurance number
You can find this on payslips or
letters from Department of
Works and Pensions or the
tax office.
/ /
/ /
Home Work Mobile Textphone Home Work Mobile Textphone
/ /
/ /
Letters Numbers
Letter
Letters
Numbers
Letter
If you do not have a National
Insurance number, or cannot find it,
If your partner does not have a
National Insurance number, or
tick this box.
cannot find it, tick this box.
Council Tax Support Claim
Form
We must see evidence of you and your partner’s identity and National Insurance
number. Read the checklist in part 15.
Part 1 About you and your partner – continued
page 4
Have you or your partner
claimed Council Tax Support,
Housing Benefit or Council
Tax Benefit before?
If you have moved home in
the last 12 months, tell us
your last address.
Were you the home owner,
a private tenant, a council
tenant or a boarder at this
address?
Have you or your partner
come to live in England,
Northern Ireland, Scotland,
Wales, the Republic of Ireland,
the Channel Islands or the Isle
of Man in the last 2 years?
What is your nationality?
If your nationality is not
British, on what date did
you settle in the UK (please
don’t include times when you’ve
been on holiday outside of the UK)?
The UK is England, Northern Ireland,
Scotland and Wales.
You Your partner
No
No
Yes
When did you claim?
Yes
When did they claim?
/ /
Which council did you claim from?
What name did you claim in?
What address did you claim for?
Postcode
Postcode
No
Yes
We will write to
you about this.
/ /
/ /
Which council did they claim from?
What name did they claim in?
What address did they claim for?
Postcode
Postcode
No
Yes
We will write to
you about this.
/ /
Are you living away from
No
home at the moment?
Yes
Tell us why you are not living at home.
When did you last live at home?
/ /
When do you expect to go back home?
/ /
Tell us the address where you are living at the moment.
Postcode
If your home has been sublet, tell us who lives there now.
Part 1 About you and your partner – continued
page 5
You Your partner
Do you or your partner get
No
No
Disability Living Allowance?
Yes
Yes
No
No
Yes
Yes
Are you or your partner in
hospital at the moment?
No
Yes
When did you go in?
/ /
When will you come out
(if you know this)?
/ /
No
Yes
When did they go in?
/ /
When will they come out
(if they know this)?
/ /
Do you or your partner get
Do you or your partner get
Personal Independence
Payment?
Attendance Allowance?
Does anyone get Carer’s
Allowance for looking
after you or your partner? (If anyone claims Carer’s Allowance for looking after you in the future please let us know)
Have you or your partner ever
claimed Carer’s Allowance?
Still tick ‘Yes’ if you claimed but
were not paid any money.
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
Yes
/ /
Due Date
Do you or your partner have
a vehicle from a mobility
scheme?
Are you or your partner a
student?
Do you study full time or part time?
No Yes
Do they study full time or part time?
No Yes
Full time
Tick if you or your partner are:
an apprentice
on youth training
in legal custody
severely mentally impaired
registered blind
long-term sick or disabled
Part time Full time Part time
No
No
Yes
Yes
Is anyone in the household
pregnant?
If Yes’, who?
Part 2 About children
page 6
First child
/ /
Second child
/ /
Third child
/ /
Fourth child
/ /
No
No No NoYes Yes Yes Yes
No No NoYes Yes Yes Yes
F
No No No No
Yes Yes Yes Yes
If yes, please tell us the
If yes, please tell us the If yes, please tell us the If yes, please tell us the
name and registration
name and registration name and registration name and registration
number of the childcare
number of the childcare number of the childcare number of the childcare
provider.
provider. provider. provider.
How much do you
pay a week?
£
How much do you
pay a week?
How much do you
pay a week?
No No No No
Yes Yes Yes Yes
How much do you
pay a week?
£ £ £
Surname or family name
First name(s)
Date of birth
What is the child’s sex?
The child’s relationship to you
The child’s relationship to your
partner
Usual address if different
from yours
Child Benefit number
Who gets the Child Benefit
for them?
Does the child get Disability
Living Allowance?
Is the child registered blind?
No
Does this child get
Do you pay a registered
childminder, nursery or
after-school club any
childminding costs for this
child?
Personal Independent
Payment?
Are there any children in your
household? By children we mean
under 16 or aged 16 to 20 and in
full-time education or approved
training.
Go to Part 3.
No
If there are more than 4 children, send us the details in an email.
Yes
Part 3 About other people who live with you
First person
Surname or family name
Other names
Date of birth
National Insurance Number
Their relationship to you or
your partner Some examples are
aunt, brother, daughter, father, grandson, grandmother, stepdaughter, joint tenant, joint owner, subtenant, lodger or friend.
/ /
Second person
/ /
Third person
/ /
When did they move in?
/ /
/ /
/ /
page 7
Are they a full-time student,
a student nurse, a care
worker, an apprentice or on
youth training?
No
Yes
No
Tell us which.
Yes
No
Tell us which.
Yes
Tell us which.
Do they receive any
State Benefits?
No
Yes
No
Tell us which.
Yes
No
Tell us which.
Yes
Tell us which.
Do they normally work?
No
Yes
Please tell us their
gross earnings and
number of hours
they work
Please tell us their
gross earnings and
number of hours
they work
Please tell us their
gross earnings and
number of hours
they work
No
Yes
No
Yes
Are they severely
mentally impaired?
No
Yes
No
Yes
No
Yes
Are they in legal custody
at the moment?
No
Yes
When are they
expected to be
released?
When are they
expected to be
released?
When are they
expected to be
released?
No
Yes
No
Yes
/ /
/ /
/ /
Are they in hospital
at the moment?
No
Yes
When did they
go in?
No
Yes
No
When did they
go in?
Yes
When did they
go in?
/ /
/ /
/ /
When will they come out
(if you know this)?
When will they come out
(if you know this)?
When will they come out
(if you know this)?
/ /
/ /
/ /
Are any of the people who
live with you married to
each other, civil partners
of each other, or living
together as if they are
married or civil partners?
No
Yes
Tell us their names.
is the
partner of
And
is the
partner of
Do any adults usually live with
you and any partner you have?
By adults we mean people over 16 who nobody gets Child Benefit for. Do not tell us about people who just share a hall,
bathroom or toilet with you. If you want to tell us about more than 3 people, tell us in an email.
No
Yes
Go to Part 4.
Answer all questions in this section.
Part 4 About Universal Credit, Income Support, Jobseeker’s
Allowance, Pension Credit and Employment and Support
Allowance
You Your partner
Are you or your partner getting
Universal Credit,Income Support,
Jobseeker's Allowance, Pension
Credit or Employment and
Support Allowance at the
moment?
No No
Yes
When did they start
When did you start
Yes
getting it?
getting it?
/ / / /
Are you or your partner still
waiting to hear about a claim
for Universal Credit, Income
Support, Jobseeker’s Allowance,
Pension Credit or Employment
and Support Allowance?
No
Yes
No
When did you claim?
Yes
When did they claim?
/ / / /
page 8
Part 5 About benefits, tax credits and state pensions
Are you or your partner getting any of the benefits or credits listed
below, or are you waiting to hear about benefits or credits you have
No
?
Go to Part 6.
claimed? Read the list of benefits and credits below and tell us about
any that you or your partner are getting now or have claimed.
Yes
?
Tell us about the benefits
below.
Pension Credit (Savings Credit)
State Retirement Pension £
£
Widows Allowance or
Bereavement Allowance £
Widowed Parents Allowance
or Widows Pension £
War Widows or War
Dependants Pension £
War Disablement Pension £
Industrial Injury/Disablement
Pension £
Exceptionally Severe
Disablement Allowance
£
£
£
£
£
£
£
£
£
Benefits and Allowances
Contribution-based Job
Seekers Allowance
£
Child Tax Credit
Working Tax Credit
£
£
Employment Training Allowance
Child Benefit
£
Employment and Support
Allowance - contribution based
£
£
Attendance Allowance £
Disability Living Allowance:
Mobility Component
£
Care Component £
£
£
£
£
£
Incapacity Benefit £ £
£
£
£
£
Yes How much How often Yes How much How often
Pensions do you get? is it paid? do they get? is it paid?
You Your partner
Part 5 About benefits, tax credits and state pensions
Personal Independence Payment
Carer’s Allowance
Severe Disablement Allowance
£
Maternity Allowance
£
Fostering Allowance
£
£
Any other benefit, pension or
Universal Credit
£
money from the government
£
£ £
£
£
£
£
£ £
Are you repaying a Social Fund
loan or overpayment for any of
these benefits?
No
Yes
I
f yes, which one?
Have you or your partner
deferred (put off) receiving a
pension?
No
Yes
If yes, please g
ive details
Part 5 About benefits, tax credits and state pensions
page 9
You Your partner
Part 6 Income other than earnings
Do you or your partner have any money coming in (or expect to
have some money coming in) that you have not already told us
about on this form?
You do not need to tell us about payments from the Independent
Living Fund, the Eileen Trust or the Macfarlane Trust.
You
Yes How much How often
Private Pension 1 paid by do you get? is it paid?
Private Pension 2 paid by
£
Date of next increase
/ /
No
Go to Part 7.
Yes
Complete the questions as below.
Your partner
Yes How much How often
do they get? is it paid?
£
Date of next increase
/ /
£
Date of next increase
/ /
£
Date of next increase
/ /
P
Please attach separate sheet ifyou have more than 2 pensions
ension Protection Fund
Payments
£
Y
Annuities
outh Training Scheme
payment or Training Credits
£
Maintenance for your child
- including CSA
Maintenance for you
£
Student grant or loan £
Payments from boarders £
Weekly amount from letting
or sub-letting part of a property £
Payments from a charity £
Any other income e.g. Redundancy
or Loan Protection Payments
(please give name)
£
£
£ £
£
£
£ £
£
£
£
£
£
We must see evidence of any money or pension coming in before we can decide how much Support you
can get. Read the checklist at Part 15 to see what you can use as evidence.
Part 7 About working for an employer
Go to Part 8.
No
Answer the questions
in this section.
Yes
No
Tell us about all the employers in an email.
Yes
Go to Part 8.
No
Answer the questions
in this section.
You Your partner
Do you or your partner work for
Yes
No
Yes
an employer?
Do you work for more than one
employer?
What kind of work do you do?
page 10
p
What is your employer’s
name and address?
When did you start this job?
How often do you get paid?
How much do you get paid
before tax and National
Insurance are taken off?
How are you paid?
For example, in cash, by cheque
or straight into a bank or building
society account.
How many hours a week do you
usually work?
Give details of any regular
overtime, bonuses, commission
or tips.
Are you getting Sick Pay,
Maternity Pay, Paternity Pay or
Adoption Pay from your employer
at the moment?
When did it start?
Postcode
/ /
Every
£
No
Yes
/ /
Postcode
/ /
Every
£
No
Yes
/ /
Do you pay into a private or
No
No
company pension scheme?
Yes
How much?
Yes
How much?
£
£
How often?
How often?
Every
Every
We must see 5 weekly, 3 fortnightly or 2 monthly consecutive of your most recent pay slips before we can
decide how much Support you can get. Read the checklist at Part 15 to see what you can use as evidence.
Part 8 About being self-employed
You Your partner
Ar
You must send us your trading accounts for the last financial year.
If you have only recently set up the business and do not have a full year’s accounts,
we will need to see some other evidence of your income.
We will write to you about this.
e you or your partner
self-employed?
No
Yes
Go to Part 9.
Answer the questions
on this page.
No
Yes
Go to Part 9.
Answer the questions
on this page.
No
Are you a company director?
If you answered ‘Yes’, you will
need to provide your payslips.
No Yes Yes
What kind of work do you do?
When did the business start?
What is the business address?
/ /
/ /
Postcode
Postcode
Are there any other partners
in the business?
Tell us their name
and address.
Tell us their name
and address.
p p p
No NoYes Yes
How much? How much?
NoNo YesYes
How much? How much?
NoNo YesYes
Postcode
Postcode
How many hours a week
do you usually work?
Do you get a Business
Start-up Allowance?
Do you pay into a private
pension scheme?
£
How often?
£
How often?
How often?
How often?
£
page 11
Every Every
Every Every
We must see evidence of your earnings before we can decide how much Support you can get. Read the checklist
at Part 15 to see what you can use as evidence.
Part 9 About any other work
Do you or your partner do
No
Go to Part 10.
any other work?
Answer the questions on
this page.
This could be voluntary work,
No
Yes
Go to Part 10.
Answer the questions on
this page.
Yes
therapeutic work or any other
work.
You Your partner
What other work do you do?
Postcode
What is the name and
address of the person you do
this work for?
Postcode
Do you get paid for this work ?
No No
Yes Yes
How much? How much?
£ £
How often? How often?
Every Every
When did you start this work?
/
/
/ /
How many hours a week do
you usually work?
page 12
We must see evidence of any earnings before we can decide how much Support you can get.
Read the checklist at Part 15 to see what you can use as evidence.
Part 10
About bank accounts, savings, investments and property
Do you or your partner have any
bank accounts, savings, property
or investments in the UK or abroad?
This includes cash, current accounts and savings accounts with a bank or building society, post office accounts,
Premium Bonds, National Savings Certificates, stocks, shares and property.
You Your partner
No Go to part 11
Yes
Answer all the questions in this part.
No
Yes
Do you have bank, building
Please answer these questions for yourself and your partner. Please include empty and overdrawn accounts, whether
in one name or jointly held with anyone else.
society or post office accounts?
(including current accounts)
If yes, please tell us the balance
of your accounts
D
Account number/name/other detail
N
We may ask to see evidence of all capital, savings and investments. Read the checklist at Part 15 to see what you
can use as evidence.
s
Your
balance/value
Partner's
balance/value
No
Yes
£ £
£ £
£ £
£ £
£ £
£ £
£ £
£ £
Part 10
About bank accounts, savings, investments and property
Do you have stocks, shares,
unit trusts?
If yes, list the names of
investments and number of
shares held.
Name Number held
No
Yes
Do you have National
Savings Certificates?
If yes, list the issue, purchase
date and number of units.
No
Yes
page 13
Have you or your partner
No
received any backdated
benefit or deferred
Yes
If ‘Yes’ please give details.
payments, such as State
pension, which you have
added to your savings?
Do you or your partner own
or partly own any property or
land except the home you live in,
either in the UK or abroad?
Tick Yes, even if you have a
mortgage or loan for the
property or land. This includes
jointly owned properties.
No
Yes
How much i £
£
s it worth?
If you have a mortgage or loan for
this, how much is left to repay?
What is the address?
Postcode
Have you or your partner
received a compensation
payment relating to the
Second World War?
No
Yes
Do you have other
investments, redundancy
payments, premium bonds,
Tessas, ISAs, SAYE, cash etc?
If yes, please give details.
(Please also use this space if
you need to tell us more about
any of the above savings.)
No
Yes
Part 11 About where you live
page 14
Who is liable for council tax
at this address?
Please tick to show if the
property is let as:
furnished
partly furnished
minimally furnished
unfurnished
This means completely furnished.
This means some furniture, but not all.
This means just two or three items.
This means no furniture at all.
No
Yes
No
Yes
What is the address?
Postcode
Do you use your
home for business purposes?
Do you have a main home
somewhere else?
If your main home is
somewhere else in the UK
or abroad, tick ‘Yes, even if
you do not pay rent for it.
Part 12 Your Council Tax Support Award
We will write to you about your Council Tax Support award. If you are awarded Council Tax Support, your Council
Tax bill will be reduced and you will be sent a new bill with details about the amount you have to pay.
We may contact you occasionally about your claim. Usually, we will send you a letter, however, if you are happy to
be contacted by email as well, please enter your email address below.
Part 13 Anything else you need to tell us
Use the box below to tell us anything else you think we should know about.
Part 14 Declaration
p
Even if someone else has partly or fully filled in this form for you, you MUST sign this declaration if you can.
If you have a partner, it would be helpful if they sign below to confirm that all the details about them are correct.
Please read this declaration carefully before you sign and date it.
I understand the following:
If I give information that is incorrect or incomplete, you may take action against me. This may include court action.
You will use the information I have provided to process my claim for Council Tax Support, or to assess any discount or
grant for Council services. You may check the information with other sources as the law allows.
You may use any information I have provided for this and any other claim for social security benefits that I have made
or may make. This includes any Discretionary Housing Payment. You may give some information to other government
organisations, such as government departments and local councils, if the law allows this. The council may share data with
the government in order to combat fraud and reduce error and this includes the use of tracing agents.
I know I must let the Council's Benefit Section know immediately in writing about any change in my
circumstances or the circumstances of anyone living with me, which might affect my claim. If I do not, you may take action
against me. This may include court action.
I declare that this is my claim for Council Tax Support and the information I have given on this form is correct and complete. I
authorise the Council to make any necessary enquiries to check that the information is true and correct.
page 15
Date
/ /
If this form has been partly or fully filled in by someone who is not the person claiming, please tell us why you are
filling in this form for the person claiming.
As far as possible, I have confirmed with the person claiming that the answers I have written on this form are correct.
Name of the person who filled in the form
/ /
Signature of the person
Relationship to the person claiming
Date
If I am making this claim on behalf of the above person, I understand that I am liable for what I have written on the form
and accept that the declaration applies to me.
Please tick the box to confirm that you have read and
understood the declaration, and understand your
responsibilities to report any changes in your circumstances to
the Council.
If you do not provide all the evidence we need, we might not be able to reduce your Council Tax. We need the
same evidence for your partner, if you have one, and for any other adults living in your home.
If you cannot send the evidence we need at the moment, send the form back to us now and send the evidence later.
We can start to process your claim, but we will not be able to make any award until we have all the evidence.
Please tell us now in Part 13 if you cannot supply the evidence within one month.
Evidence of identity - This is usually anything that has your full name and date of birth on it
Evidence of your National Insurance Number - This could be any document that has your National Insurance
Number on it
Evidence of savings, investments and property - This means all of your bank accounts, savings accounts, shares,
premium bonds or other investments or property. We will need to see the last 2 months statements for any accounts.
Evidence of earnings for all adults in the property – We need to see your payslips (your last 5 if you are paid week-
ly, your last 3 if you are paid every 2 weeks or your last 2 if you are paid monthly). If you are self-employed, you
will need to complete an additional form. Please contact us so that we can send you one.
Evidence of other income – this means money from pensions or gifts of money that people have given to you.
Evidence of benefits, Tax Credits or Pension Credit – any letters from the DWP or HMRC confirming how much you
get.
Evidence of other money you pay out – this means receipts from registered child carers or financial help you give
to a student.
If you would like us to discuss your claim with someone else who is helping you, you will need to complete a third
party authorisation form. Please contact us so that we can send you one.
Part 15 Checklist
page 16
If you know or suspect someone is committing benefit fraud, you can report them direct without having to give your
name or details by:
• writing to the Council
• phoning: 01442 228291 - or National Hotline number 0800 854 440;
• e-mailing to FraudHotline@dacorum.gov.uk; or going on our website: www.dacorum.gov.uk
Please now email your completed form to benefits@dacorum.gov.uk
Part 16 Ethnic Background
by ticking o
A
Br tish
i
Other
Ban
Anything else you want to tell us about that may affect your claim
The government has asked us to gather information about our customer’s ethnic background. It’s your choice whether to fill
in this section. Please show which of the following groups you and your partner (if any) consider you belong to by ticking
one box for you and one for your partner.
White
British
Irish
Other white
Mixed
White and black Caribbean
White and Asian
Other mixed
Chinese
Other
Asian
Asian British
Bangladeshi
Indian
Kashmiri
Pakistani
Other Asian
Black British
Caribbean
African
Other black
You
Your
partner
You
Your
partner
White and black African
page 17
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