Shortened claim form for
Council Tax Support
Revenues and Benefits
PO Box 866
Taunton
TA1 9GS
Tel: 0300 304 8000
Monday-Friday 8am to 6pm
Version 1.0 April 2020
About the form and the proof we need
This form asks you for information so we can work out your Council Tax Support.
Fill in the form using black ink and place a tick () in relevant boxes. Remember to read and sign
the declaration in Part 12.
If you are getting Universal Credit you need to provide screen shots of all the pages of your award
summary from your online account.
Do not send this form back until you have all the proof you need to go with it. This helps us
provide a better service. You have one month to give us the completed form and all the proof we
need. The sooner we get your form back, the sooner we can work out your Council Tax
Support. In the meantime you must continue to pay your Council Tax.
Part 1. You and your partner
By partner we mean:
A person you are married to or a person you live with as if you are married to them; or
A civil partner or a person you live with as if you are civil partners
Yes
No
You
Your partner
Surname or family name
First name(s)
Title (Mr, Mrs, Ms, other)
Date of birth
/ /
/ /
National Insurance Number
Please tell us the full address of
the property you want to claim for
including room number
Do not tell us your partner’s address
if it is the same as yours.
What date did you move in?
/ /
/ /
Contact telephone number
Email address
Due to COVID-19 our offices are closed.
Please do not write to us or send us your
claim through the post.
Download this claim form and fill it in electronically.
When you have finished, save it to your device.
The checklist tells you the evidence we need to see to
assess your claim. Use a smartphone or mobile device
to take photographs of the evidence you need to
support your claim.
Send your completed claim form and photos of your
evidence to benefits@somersetwestandtaunton.gov.uk
Part 1. You and your partner (continued)
You
Your partner
Please tick if you or your partner is:
registered blind
on youth training
in legal custody
severely mentally impaired
an apprentice
Are you or your partner a care
leaver?
Yes
No
Yes
No
By care leaver, we mean a person who spent at least 13 weeks in foster or residential care, or in
other arrangements outside their immediate or extended family, on or past their 16
th
birthday.
Part 2. Children
We need to know about any children normally living with you who are:
under 16;
aged 16 or 17 and registered for work or youth training; or
aged 16, 17, 18 or 19 and in education doing a course not higher than
GCE A-level, SCE Higher level or GNVQ (advanced), or undertaking an approved training course
Are there any children in your household?
No
Go to Part 3
Yes
First child
Second child
Their full name
Relationship to you
Date of birth
/ /
/ /
Child Benefit number
Are they registered blind or
getting DLA or PIP?
Yes
No
Yes
No
Third child
Fourth child
Their full name
Relationship to you
Date of birth
/ /
/ /
Child Benefit number
Are they registered blind or
getting DLA or PIP?
Yes
No
Yes
No
If you have more than four children, use the space in Part 10 to tell us all the information we
ask for in Part 2.
Do you pay for childcare to a registered childminder,
nursery or after school club?
Yes
No
Which children receive the childcare?
How much do you pay
£
How often do you pay?
every
Part 3. Other people who live with you
Do any adults usually live with you and your
partner (if you have one)?
No
Go to Part 4
Yes
Tell us about all the people (except your partner) who usually live with you. If you want to tell us
about more than 4 people, use the space in Part 10 to tell us all the information we ask for in Part 3.
First person
Second person
Full name
Date of birth
/ /
/ /
Their relationship to you
For example: brother, daughter, stepson, stepdaughter, joint tenant, lodger, boarder or friend
National insurance number
Are they a full-time student,
a student nurse, a care
worker, an apprentice or on
youth training?
Yes
No
Yes
No
Are they severely mentally
impaired?
Yes
No
Yes
No
Third person
Fourth person
Full name
Date of birth
/ /
/ /
Their relationship to you
For example: brother, daughter, stepson, stepdaughter, joint tenant, lodger, boarder or friend
National insurance number
Are they a full-time student,
a student nurse, a care
worker, an apprentice or on
youth training?
Yes
No
Yes
No
Are they severely mentally
impaired?
Yes
No
Yes
No
Part 4. Benefits you are claiming
people who live with you
Are you or your partner getting or waiting to hear
about a claim for:
Universal Credit
Jobseekers Allowance (income-based)
Employment & Support Allowance (income-related)
Pension Guarantee Credit
Income Support
No
Go to Part 5
Yes
If Yes, which benefit are you getting or waiting for?
When did you start getting it or make your claim?
/ /
Part 5. Working for an employer
Do you or your partner work for an employer?
No
Go to Part 6
Yes
If you work for more than one employer, tell us in Part 10 all the information we ask for in Part 5.
You
Your partner
What kind of work do you do?
What is the name and address
of your employer?
Postcode
Postcode
How many hours a week do
you work?
How often do you get paid?
every
every
How much do you normally
earn every week, or month?
£ every
£ every
When was your last pay rise?
/ /
/ /
How are you paid?
For example, by cash, cheque
or straight into a bank account?
Do you pay into a pension scheme?
Yes
No
Yes
No
If Yes, how much do you pay?
£ every
£ every
We must see proof of your earnings. The checklist in Part 11 tells you what we need.
Part 6. Self-employment
employer
Are you or your partner self-employed?
No
Go to Part 7
Yes
You
Your partner
When did you start this job?
/ /
/ /
What kind of work do you do?
What is the business name
and address?
Postcode
Postcode
How many hours a week do
you work?
Do you pay into a pension
scheme?
Yes
No
Yes
No
If Yes, how much do you pay?
£ every
£ every
We must see proof of your self-employment income. See the checklist in Part 11.
Part 7. Benefits, pensions & allowances
Are you or your partner getting any benefits,
pensions or allowances or are you waiting to
hear about a claim?
No
Go to Part 8
Yes
Read the lists below and tell us about any benefits, pensions or allowances you or your partner
have claimed or get now. Tell us the full rate of benefits, pensions or allowances before deductions.
Benefits for illness or disability
Other Benefits
Attendance Allowance
Carer’s Allowance
Disability Living Allowance
Employment and Support Allowance
Industrial Death Benefit
Industrial Injuries Disablement Benefit
Personal Independence Payment
Statutory Sick Pay
War Disablement Benefit
Bereavement Allowance
Child Benefit
Child Tax Credit
Fostering or adoption allowance
Government Training Allowance
Guardian’s Allowance
Jobseeker’s Allowance (contributions-based)
Maternity Allowance
Statutory Adoption pay
Statutory Maternity or Paternity Pay
Widow’s or Widower’s Benefit
Working Tax Credit
Pensions
Pension Credit
State Retirement Pension
War Pension or War Widow’s Pension
If you are getting or have claimed any benefit not listed, make sure you tell us about it
You
Your partner
For each benefit, pension or
allowance you get, tell us:
Which one you get
How much you get
How often you get it
Part 8. Any other income
Do you, your partner, or any children you are
claiming for, have any money coming in
(or expect to have some money coming in)
that you have not already told us about ?
We need to know about:
No
Go to Part 9
Yes
Private pensions
Occupational pensions
Work pensions
Any other pension
Training allowances
Charitable income
Student grants or loans
Early Years Grant
Money from a trust fund
Income from accommodation
you rent out
Income from a boarder or
lodger
Income from a directorship
of a limited company
Maintenance or support you
receive for your children
Any money you expect to
get in the next 12 months
Any other income you have
not already told us about
Use this space to tell us:
What the money is for
Who receives it
How much they get How
often
When did this income start
When it is likely to go up
We must see proof of your income. The checklist in Part 11 tells you what we need.
Part 9. Bank accounts, savings and investments
You must tell us about ALL accounts you have, even if the account has a nil or overdrawn
balance. If you do not have an account, write “none”. If you’re overdrawn, write “overdrawn”.
If you have any money or investments abroad, you must tell us.
You
Your partner
Bank account(s)
£
£
£
£
Building society account(s)
£
£
Post office accounts
£
£
Please tell us the account
numbers for any accounts
listed above
Use the space below to tell us about any other savings or investments you have, such as:
Accounts, savings,
investments or any money
held abroad
Any property you own or
have a financial interest,
here or aborad
National Savings Income
bonds
PEPs, TESSAs and ISAs
Stocks, shares or unit
trusts
National Savings
Certificates
Premium bonds
Cash savings
Part 10. Any other information
Is there any other information you think we
should know?
No
Go to Part 11
Yes
Tell us any extra information below
Part 11. Checklist
If you do not provide all the evidence we need, we may not be able to pay you any benefit.
Do not send this form back until you have all the proof you need to go with it. This helps us
provide a better service. You have one month from the date of issue to give us the completed form
and all the proof we need.
Evidence of earnings from employment
We need to see the last 5 weekly payslips or last 2 monthly payslips or a
Evidence of earnings from self-employment
If you are about to start or have only just started self-employment, phone us on 0300
304 8000 for more information.
If you have been self-employed for more than one year, we need you to provide your
most recent audited trading accounts or complete the ‘self-employed income and
expenditure certificate’ and give us details of your self-employment for the last 12 months.
Evidence of benefits, pensions and allowances
Such as current award notices, pension or order books or letters from the DWP or HM
Revenue and Customs showing how much is received.
Evidence of any other income
Such as a recent letter, grant notification or advice slip from the person or organisation
paying the money or a letter from the Court showing maintenance payments. We need to see
evidence of any money people pay you for accommodation.
Evidence of money you pay out
If you pay for childcare, we need to see a recent letter from the childcare provider giving
their name and address, names of the children receiving care, the amount charged and the
registration number if applicable.
If you pay into a pension scheme, we will need a recent letter from the pension company
showing the amount and frequency of payments, payslips showing the amount and
frequency of pension contributions.
Evidence of capital, savings and investments
Such as bank statements, building society statements or passbooks, Post Office passbooks,
certificates for premium bonds, National Savings, ISAs, PEPs, TESSAs, stocks, shares,
income bonds and unit trusts.
The evidence you send must show transactions for at least the last 2 months
Part 12. Declaration
I declare that the information I have given on this form is correct and complete.
I know the information I give will be used to work out any Council Tax Support I may be due
through Council Tax Reduction under S13A and Schedule 1a of the Local Government Finance
Act 1992.
I understand that if I give information that is incorrect or incomplete, you may take action against
me. This may include court action.
I agree to tell Somerset West and Taunton Council immediately, in writing, about any change in
my circumstances that might affect my award.
I know that if I do not report any changes affecting my support, or I give incorrect or incomplete
information, I must pay any Council Tax that becomes due.
You
Your partner
Signature
Date
/ /
/ /
Use a smartphone or mobile device to take photographs of the evidence
you need to support your claim. Send the claim and evidence to us by email.
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